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Choi GW, Yun WG, Lee M, Jung HS, Cho YJ, Han Y, Kwon W, Jang JY. Prognostic implications of resection margin status in distal pancreatectomy for pancreatic ductal adenocarcinoma. HPB (Oxford) 2025:S1365-182X(25)00545-3. [PMID: 40287296 DOI: 10.1016/j.hpb.2025.04.001] [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: 08/11/2024] [Revised: 01/21/2025] [Accepted: 04/01/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Curative resection is a well known prognostic factor in pancreatectomy. However, definition and clinical significance of resection margin in distal pancreatectomy remains controversial. METHODS From 2010 to 2018, 203 patients with pancreatic cancer undergoing distal pancreatectomies were included. Patients were classified into three groups: R0-wide (tumor-free margin ≥1 mm), R0-narrow (0 mm < tumor-free margin <1 mm), and R1 margin (tumor-free margin = 0 mm). We also evaluated the prognostic impact of individual margins (transection, anterior, and posterior). RESULTS Patients with an R0-wide margin (36.6 %) exhibited superior 5-year disease free survival rate compared to those with R0-narrow (30.4 %, p = 0.059) or R1 margin (0.1 %, p = 0.014). However, in multivariate analyses, only R1 margin (hazard ratio [95 % confidence interval], 2.02 [1.32-3.12]; p = 0.001), unlike R0-narrow margin (1.17 [0.78-1.77]; p = 0.446), was linked to shorter overall survival compared to R0-wide margin. In multivariate analyses, posterior margin involvement was uniquely identified as a poor prognostic factor (1.83 [1.07-3.13]; p = 0.027). CONCLUSIONS The 0 mm rule seems more suitable than the 1 mm rule for predicting prognosis in performing distal pancreatectomy, and especially, achieving microscopically negative posterior margin is crucial.
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Affiliation(s)
- Go-Won Choi
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Young J Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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Jiang X, Zhu Y, Li J, Li W, Zheng W, Xu C, Zhang G. Laparoscopic radical antegrade modular pancreatosplenectomy vesus laparoscopic distal pancreatosplenectomy for left-sided pancreatic cancer: a systematic review and meta-analysis. Front Oncol 2025; 15:1510342. [PMID: 40027121 PMCID: PMC11867953 DOI: 10.3389/fonc.2025.1510342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2024] [Accepted: 01/24/2025] [Indexed: 03/05/2025] Open
Abstract
Objective We aimed to compare the perioperative outcomes and postoperative complications of laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) versus laparoscopic distal pancreatosplenectomy (L-DPS) for left-sided pancreatic cancer through a meta-analysis. Methods A systematic review and meta-analysis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, were performed. Literature searches were conducted in PubMed, Web of Science, Cochrane Library, and Embase for studies published from their inception up to June 14th, 2024. Results A total of three retrospective studies involving 242 patients were included in this meta-analysis, with 116 patients in the L-RAMPS group and 126 in the L-DPS group. The meta-analysis results indicated that L-RAMPS was associated with the retrieval of more lymph nodes (MD: 3.06; 95% CI: 2.51 to 3.62, p < 0.00001) and longer operative time (MD: 20.05; 95% CI: 13.97 to 26.12, p < 0.00001) compared to L-DPS for left-sided pancreatic cancer patients. However, no significant differences were observed between the two groups in terms of R0 resection margins, the incidence of pancreatic fistula (Grade B and C), postpancreatectomy hemorrhage, or postoperative complications (Clavien-Dindo Grades II and III). Conclusions In patients with left-sided pancreatic cancer, L-RAMPS resulted in the retrieval of more lymph nodes, a longer operative time, and a similar incidence of postoperative complications compared to L-DPS. Larger sample sizes, extended follow-up periods, and well-conducted randomized controlled trials are needed to further validate these findings. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=558977, identifier CRD42024558977.
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Affiliation(s)
- Xutao Jiang
- Department of General Surgery, the Second Hospital of Dalian Medical University, Dalian, China
- Department of General Surgery, Dongxiang District People's Hospital, Fuzhou, China
| | - Yu Zhu
- Department of General Surgery, Dongxiang District People's Hospital, Fuzhou, China
| | - Jianwei Li
- Department of Intensive Care Medicine, Dongxiang District People's Hospital, Fuzhou, China
| | - Wei Li
- Department of General Surgery, Dongxiang District People's Hospital, Fuzhou, China
| | - Weizong Zheng
- Department of General Surgery, Dongxiang District People's Hospital, Fuzhou, China
| | - Caiming Xu
- Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, Comprehensive Cancer Center, Monrovia, CA, United States
- Department of General Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guixin Zhang
- Department of General Surgery, the Second Hospital of Dalian Medical University, Dalian, China
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
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Zhou Y, Xue F. A comparative analysis and survival analysis of open versus minimally invasive radical antegrade modular pancreatosplenectomy for pancreatic cancer: a systematic review and meta-analysis. Front Oncol 2025; 14:1513520. [PMID: 39917364 PMCID: PMC11798776 DOI: 10.3389/fonc.2024.1513520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 12/31/2024] [Indexed: 02/09/2025] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is a major public health concern, ranking as the fourth leading cause of cancer-related mortality in the United States. Traditional surgical approaches often yield suboptimal outcomes, highlighting the need for innovative surgical strategies. Radical antegrade modular pancreatosplenectomy (RAMPS) has demonstrated improvements in surgical visualization and oncological outcomes. Recently, laparoscopic RAMPS (L-RAMPS) has been introduced as a minimally invasive alternative. Objectives This meta-analysis aims to compare the safety and efficacy of open RAMPS (O-RAMPS) versus L-RAMPS, focusing on operative outcomes, minimally invasive outcomes, intra-abdominal outcomes, overall postoperative outcomes, and oncologic outcomes. Methods A systematic review and meta-analysis were conducted following PRISMA guidelines. Eligible studies included prospective or retrospective cohort studies and randomized controlled trials comparing L-RAMPS with O-RAMPS. Data were extracted from EMBASE, PubMed, and the Cochrane Library databases through September 16, 2023. The ROBINS-I tool was used to assess the risk of bias. Statistical analyses included odds ratios (OR), risk differences (RD), mean differences (MD), and survival analyses. Results Eight studies involving 588 patients were included. O-RAMPS was associated with longer operative times (MD = 39.39 minutes, 95% CI = 22.93 to 55.84) and greater blood loss (MD = -231.84 mL, 95% CI = -312.00 to -151.69). No significant differences were observed in blood transfusion rates, pancreatic fistula rates, delayed gastric emptying, or length of hospital stay. L-RAMPS demonstrated a shorter time to oral feeding (MD = -0.79 days, 95% CI = -1.35 to -0.22). Survival analysis suggested a potentially improved long-term prognosis for L-RAMPS. Conclusion L-RAMPS offers advantages over O-RAMPS in terms of reduced blood loss, faster time to oral feeding, and potentially better long-term prognosis. Further research is warranted, particularly regarding the learning curve of L-RAMPS and its broader applicability. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42024498383.
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Affiliation(s)
| | - Fei Xue
- Kunshan Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu, China
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Yao R, Du F, Liu R, Tan L, Lian J, Gao L, Zhang H, Huang L, Pan B, Zhou Y, Sun Q, Zhao J, Long X. Breast Modular Resection (BMR) in Nipple-Sparing Mastectomy (NSM) With Intraoperative Laser Speckle Contrast Imaging (LSCI) Monitoring Improved Surgical Training Outcome Among Fellows. Clin Breast Cancer 2024; 24:705-715. [PMID: 39289111 DOI: 10.1016/j.clbc.2024.08.011] [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] [Received: 06/09/2024] [Revised: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are challenging for surgical training among fellow trainees. We developed a surgical training course with novel concept of breast modular resection (BMR) for NSM/SSM procedure, and performed this study to investigate whether BMR could improve surgical outcomes compared to classical procedure resection (CPR). METHODS The records of 105 breast cancer patients undergoing NSM/SSM with immediate reconstruction performed by fellow trainees were reviewed. Clinicopathological characteristics and surgical outcomes were compared between 2 groups. Laser speckle contrast imaging (LSCI) was performed to intraoperatively evaluate the blood supply of the NAC, and the absolute perfusion unit (PU) values and relative perfusion unit (rPU) values were further compared. RESULTS Surgical training outcomes of BMR group (N = 52) were insignificantly improved compared to CPR group (N = 53). The rates of NAC necrosis, flap necrosis and implant removal all reduced respectively. Among the 60 NSM patients, the blood loss (P = .011) and surgery time (P < .001) was significantly reduced in BMR group (N = 30) and all the other outcomes were insignificantly improved. Both the absolute PU values and rPU values were significantly higher among patients without NAC necrosis (P < .001). The absolute PU values were significantly higher in BMR group (P = .002). CONCLUSION Compared to CPR, the BMR-based surgical training course for NSM demonstrated the reduction in complications and operating time, offering a potential streamlined, efficient, and safe method for NSM procedure. LSCI was effective for intraoperative visualized evaluation of NAC blood supply and could provide effective real-time feedback for fellow trainees.
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Affiliation(s)
- Ru Yao
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Fengzhou Du
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Runzhu Liu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Linjuan Tan
- Department of Anesthesia and Operating Room, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Lian
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Lu Gao
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hailin Zhang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Li Huang
- Department of Education, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Pan
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Yidong Zhou
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Qiang Sun
- Department of Breast Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jun Zhao
- Department of Education, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China; Institute of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
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Sato S, Inoue Y, Oba A, Ono Y, Sato T, Ito H, Takahashi Y. Scope transition and early arterial inflow control provide safe and comfortable dissection in robotic distal pancreatectomy. Langenbecks Arch Surg 2024; 409:171. [PMID: 38829557 DOI: 10.1007/s00423-024-03372-2] [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] [Received: 03/28/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE We describe details and outcomes of a novel technique for optimizing the surgical field during robotic distal pancreatectomy (RDP) for distal pancreatic lesions, which has become common with potential advantages over laparoscopic surgery. METHODS For suprapancreatic lymph node dissection and splenic artery ligation, we used the basic center position with a scope through the midline port. During manipulation of the perisplenic area, the left position was used by moving the scope to the left medial side. The left lateral position is optionally used by moving the scope to the left lateral port when scope access to the perisplenic area is difficult. In addition, early splenic artery clipping and short gastric artery dissection for inflow block were performed to minimize bleeding around the spleen. We evaluated retrospectively the surgical outcomes of our method using a scoring system that allocated one point for blood inflow control and one point for optimizing the surgical view in the left position. RESULTS We analyzed 34 patients who underwent RDP or R-radical antegrade modular pancreatosplenectomy (RAMPS). The left position was applied in 14 patients, and the left lateral position was applied in 6. Based on the scoring system, only the 0-point group (n = 8) had four bleeding cases (50%) with splenic injury or blood pooling; the other 1-point or 2-point groups (n = 13, respectively) had no bleeding cases (p = 0.0046). CONCLUSION Optimization of the surgical field using scope transition and inflow control ensured safe dissection during RDP.
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Affiliation(s)
- Shoki Sato
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Division of Hepato-biliary-pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Ricci C, Kauffmann EF, Pagnanelli M, Fiorillo C, Ferrari C, De Blasi V, Panaro F, Rosso E, Zerbi A, Alfieri S, Boggi U, Casadei R. Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis. HPB (Oxford) 2024; 26:44-53. [PMID: 37775352 DOI: 10.1016/j.hpb.2023.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 06/25/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS. RESULTS O-RAMPS and MI-RAMPS showed "non-small" differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins. CONCLUSION In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy.
| | | | - Michele Pagnanelli
- Section of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Rome, Italy; CRMPG (Gemelli Pancreatic Advanced Research Center), Italy
| | - Cecilia Ferrari
- Department of Digestive Surgery and Transplantation, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Vito De Blasi
- Department of Surgery, Centre Hospitalier de Luxembourg, Luxembourg
| | - Fabrizio Panaro
- Department of Digestive Surgery and Transplantation, Saint-Eloi Hospital, Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Edoardo Rosso
- Department of Surgery, Centre Hospitalier de Luxembourg, Luxembourg
| | - Alessandro Zerbi
- Section of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS di Roma, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Rome, Italy; CRMPG (Gemelli Pancreatic Advanced Research Center), Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
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Sato S, Oba A, Kato T, Kobayashi K, Wu YHA, Ono Y, Sato T, Ito H, Inoue Y, Takahashi Y. Feasibility of laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) as a standard treatment for distal resectable pancreatic cancer. Langenbecks Arch Surg 2023; 408:217. [PMID: 37249638 DOI: 10.1007/s00423-023-02942-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Laparoscopic (Lap-) radical antegrade modular pancreatosplenectomy (RAMPS) is an attractive radical procedure that aims to achieve negative posterior retroperitoneal margin in pancreatic ductal adenocarcinoma (PDAC) resections. However, only few institutions are adapting Lap-RAMPS due to the technical difficulties and the lack of supporting evidence for the clinical applications. METHODS A retrospective cohort study was performed on consecutive patients who underwent RAMPS for distal resectable PDACs. We analyzed the short- and long-term outcomes including local control and the induction of adjuvant chemotherapy compared between Lap- and Open-RAMPS. RESULTS Of the 118 RAMPS patients, 43 patients underwent Lap-RAMPS and 75 patients underwent Open-RAMPS. The blood loss was lower (125 vs. 390 mL, p < 0.001), and postoperative hospital stay was shorter (17 vs. 21 days, p = 0.018) in the Lap-RAMPS group. There was no difference in the postoperative complications and no mortality in both groups. R0 resection rate was 100.0% in the Lap-RAMPS and 90.7% in the Open-RAMPS (p = 0.039). Among the patients eligible for adjuvant chemotherapy, the Lap-RAMPS group showed a favorable induction rate (100.0 vs. 89.6%, p = 0.037). Both groups showed a favorable 3-year local recurrence rate (8.7 vs. 10.0%, p = 0.976) and 3-year overall survival (69.8 vs. 71.1%, p = 0.996). CONCLUSIONS The safety and efficacy of Lap-RAMPS were comparable to those of Open-RAMPS in terms of achieving local control and adjuvant chemotherapy induction. A higher early induction of adjuvant chemotherapy is an advantage of minimally invasive surgery.
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Affiliation(s)
- Shoki Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Y H Andrew Wu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan.
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Cadili L, Vasilyeva E, Li J, Kim P, Chung S, Segedi M. Pancreas tail adenocarcinoma tumor size is highly predictive of positive margins after a nonradical resection. Am J Surg 2022; 224:728-732. [PMID: 35643634 DOI: 10.1016/j.amjsurg.2022.05.021] [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] [Received: 11/14/2021] [Revised: 04/16/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radical resection (RAMPS) of left sided pancreatic ductal adenocarcinoma (PDAC) is effective in achieving R0 margins; however, not universally accepted due to lack of improved survival. We hypothesized that only larger tumors lead to R1 in non-RAMPS procedures. METHODS A retrospective review of charts between 2008 and 2020 was performed. The primary outcome was evaluating R0 resection based on left-sided tumors' size and location, and secondary outcomes were OS and DFS. RESULTS Sixty-eight percent had R0 resection. R1 groups' tumors were larger (5.5 cm vs. 3.8 cm, p = 0.004) and had higher LVI involvement (p = 0.003). OS and DFS did not differ on multivariate analysis. Tumor size above 4 cm in the tail was associated with R1 (p = 0.01). CONCLUSIONS Larger tumors in the tail, but not body were associated with R1, but not worse survival. Perhaps larger tumors in the tail are a surrogate marker of poor disease biology.
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Affiliation(s)
- Lina Cadili
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elizaveta Vasilyeva
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Li
- Division of Liver and Pancreas Transplantation, University of California Los Angeles, Los Angeles, CA, USA
| | - Peter Kim
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Chung
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Maja Segedi
- Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Hepatopancreatobiliary and Liver Transplant Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Liu B, Wu J, Li C, Li Y, Qiu H, Lv A, Liu Q, Liu D, Wang Z, Hao C. The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor? Pancreatology 2022; 22:112-122. [PMID: 34764022 DOI: 10.1016/j.pan.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors. METHODS We retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively. RESULTS DP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS. CONCLUSION DP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.
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Affiliation(s)
- Bonan Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Jianhui Wu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Chengpeng Li
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yang Li
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Hui Qiu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ang Lv
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Qiao Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Daoning Liu
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Zhen Wang
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Chunyi Hao
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, 100142, China.
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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11
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Minimally Invasive Versus Open Radical Antegrade Modular Pancreatosplenectomy: A Meta-Analysis. World J Surg 2021; 46:235-245. [PMID: 34609574 DOI: 10.1007/s00268-021-06328-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to improve the tangential resection margin rates and N1 node clearance following resection of malignancies of the pancreatic body and tail. Owing to its technical complexity, minimally invasive RAMPS (MI-RAMPS) has only been reported by a few centers worldwide. We performed this meta-analysis to compare both short- and long-term outcomes between open RAMPS (O-RAMPS) and minimally invasive RAMPS (MI-RAMPS). METHODS A systematic search of the electronic databases PubMed, Medline (via PubMed), Cochrane Register of Controlled Trials (CENTRAL), EMBASE, Scopus and Web of Science was performed to identify eligible studies published in the English language regardless of study design. The outcomes of interest were operation time, estimated blood loss, transfusion rates, overall complications, Grade B/C post-operative pancreatic fistula (POPF) rates, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), R0 resection rates, lymph node (LN) yield and overall survival (OS). RESULTS Five non-randomized studies comprising of a total 229 patients (89 MI-RAMPS, 140 O-RAMPS) were included for analysis. Intra-operative blood loss was observed to be significantly reduced in MI-RAMPS as compared to O-RAMPS (MD -256.16, P < 0.001), while LN yield was higher in O-RAMPS as compared to MI-RAMPS (MD -2.73, P = 0.02). There were no statistically significant differences observed for the other perioperative, oncologic and survival outcomes. CONCLUSIONS This meta-analysis provides early evidence to suggest that MI-RAMPS may produce comparable short- and long-term outcomes to O-RAMPS, when undertaken by appropriately skilled surgeons in well-selected patients. Further large-scale prospective studies are required to corroborate these findings.
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Salehi O, Vega EA, Kutlu OC, Alarcon Velasco SV, Krishnan S, Ricklan D, Kozyreva O, Conrad C. Combining Appleby with RAMPS - Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection. J Gastrointest Surg 2020; 24:2700-2701. [PMID: 32557017 DOI: 10.1007/s11605-020-04686-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/02/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PATIENT: A 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response. TECHNIQUE Prior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound. CONCLUSION L-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | | | - Sandeep Krishnan
- Department of Gastroenterology, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - David Ricklan
- Department of Pathology, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA.
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13
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Kumar SS, Biswas BK, Shukla R, Sharma S, Raman DK, Saranga Bharathi R. Chemo-Resistant Locally Advanced Left-Sided Pancreatic Cancer Encasing Portal Venous Confluence, Celiac and Superior Mesenteric Arteries: Management Strategy. J Gastrointest Cancer 2020; 52:797-801. [PMID: 33000391 DOI: 10.1007/s12029-020-00527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Raj Shukla
- Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
| | - Surabhi Sharma
- Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
| | - Deep Kumar Raman
- Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
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14
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Baimas-George M, Watson M, Salibi P, Tschuor C, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Oncologic Outcomes of Robotic Left Pancreatectomy for Pancreatic Adenocarcinoma: A Single-Center Comparison to Laparoscopic Resection. Am Surg 2020; 87:45-49. [PMID: 32915060 DOI: 10.1177/0003134820949524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Feasibility and safety of robotic surgery for pancreatic disease has been well demonstrated; however, there is scarce literature on long-term oncologic outcomes. We compared perioperative and oncologic outcomes between robotic left pancreatectomy (RLP) and laparoscopic left pancreatectomy (LLP) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated left pancreatectomies performed for pancreatic adenocarcinoma from 2009 to 2019 in a tertiary institution. Baseline characteristics, operative and oncologic outcomes were compared between RLP and LLP. RESULTS There were 75 minimally invasive left pancreatectomy cases for pancreatic adenocarcinoma identified of which 33 cases were done robotically and 42 laparoscopically. Baseline characteristics demonstrated no difference in gender, age, BMI, T stage, N stage, neoadjuvant, or adjuvant chemotherapy. An analysis of operative variables demonstrated no difference in blood loss, increased duration, and higher lymph node yield with RLP (20 vs 12; P = .0029). Postoperatively, both cohorts had 30% pancreatic fistulas and no difference in complications. There were no differences in length of stay (LOS), 30- or 90-day readmission rates, or 90-day mortality. The analysis of oncologic outcomes demonstrated similar R0 resections (RLP: 72% vs OLP: 67%), recurrence rates (RLP: 36% vs OLP: 41%), and time to recurrence (RLP: 324 vs OLP 218 days). There was increased survival in the RLP cohort that was not significant (32 vs 19 months). CONCLUSION This analysis demonstrates RLP is at least equivalent to LLP in perioperative and oncologic outcomes. The significantly higher lymph node yield and trend toward an improved survival suggests oncologic advantage. Randomized controlled studies are needed to clarify benefit.
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Affiliation(s)
- Maria Baimas-George
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Patrick Salibi
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Christoph Tschuor
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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15
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Delpero JR, Sauvanet A. Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019. Front Oncol 2020; 10:40. [PMID: 32117714 PMCID: PMC7010716 DOI: 10.3389/fonc.2020.00040] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019). Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system. Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion). Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.
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Affiliation(s)
- Jean Robert Delpero
- Institut Paoli-Calmettes (IPC), Marseille, France.,Faculté de Médecine, Aix Marseille Université, Marseille, France
| | - Alain Sauvanet
- Hôpital Beaujon, Clichy, France.,Université Paris VII - Denis Diderot, Paris, France
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Lyman WB, Passeri M, Sastry A, Cochran A, Iannitti DA, Vrochides D, Baker EH, Martinie JB. Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center. Surg Endosc 2019; 33:2991-3000. [PMID: 30421076 DOI: 10.1007/s00464-018-6565-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/26/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously. METHODS 247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival. RESULTS There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP. CONCLUSIONS This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.
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Affiliation(s)
- William B Lyman
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Michael Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Amit Sastry
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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17
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Huo Z, Zhai S, Wang Y, Qian H, Tang X, Shi Y, Weng Y, Zhao S, Deng X, Shen B. Comparison of Radical Antegrade Modular Pancreatosplenectomy with Standard Retrograde Pancreatosplenectomy for Left-Sided Pancreatic Cancer: A Meta-Analysis and Experience of a Single Center. Med Sci Monit 2019; 25:4590-4601. [PMID: 31221951 PMCID: PMC6599421 DOI: 10.12659/msm.914540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported as a modified surgical technique used to achieve better margin resection and to retrieve more lymph nodes compared with standard retrograde pancreatosplenectomy (SRPS). MATERIAL AND METHODS A systematic literature review was performed to identify studies published in PubMed, EmBase, and Web of Science. Hazard ratio (HR), risk ratio (RR), weighted mean difference (WMD), and their 95% confidence intervals (95% CIs) were used as effect measures. In addition, the clinical data of 27 patients in our center were collected and retrospectively analyzed. RESULTS Seven studies containing 474 patients were finally enrolled in this meta-analysis. The pooled results showed that the RAMPS group had a better overall survival (OS) compared with the SRPS group (HR=0.65, 95% CI: 0.43-0.99, P=0.046; I²=41.8%, P=0.143). Significantly more lymph nodes were harvested in the RAMPS group compared with in the SRPS group (WMD=4.74, 95% CI: 0.36-9.12, P=0.034). Recurrence rate (RR=0.8, 95% CI: 0.66-0.98, P=0.028) and blood loss (WMD=-153.19 ml, 95% CI: -303.95 to -2.42, P=0.046) were both significantly reduced in the RAMPS group. Retrospective analysis results showed that only significantly more harvested lymph nodes were noted in the RAMPS group compared with the SRPS group (7.55±0.91 vs. 2.81±0.73, P=0.001). CONCLUSIONS Our study suggests that RAMPS has better prognosis and surgical outcomes than SRPS for left-sided pancreatic cancer. Nevertheless, more high-quality clinical trials are required to validate the result.
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Affiliation(s)
- Zhen Huo
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Shuyu Zhai
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yue Wang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Hao Qian
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Xiaomei Tang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yusheng Shi
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Yuanchi Weng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Shulin Zhao
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
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Zhou Y, Lin J, Wang W, Chen H, Deng X, Peng C, Cheng D, Shen B. Should a standard lymphadenectomy include the No. 9 lymph nodes for body and tail pancreatic ductal adenocarcinoma? Pancreatology 2019; 19:414-418. [PMID: 30902419 DOI: 10.1016/j.pan.2019.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/10/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to use a retrospective data base to investigate whether a standard lymphadenectomy during distal pancreatectomy should include the No. 9 lymph nodes (LNs) for resectable pancreatic ductal adenocarcinoma (PDAC) located in the body and tail of the pancreas. METHODS Data from 169 patients undergoing curative distal pancreatectomy for PDAC between Jan 1, 2013 and Dec 31, 2016 were collected. According to the tumor location, patients were divided into three groups: pancreatic neck tumor, pancreatic body and tail tumor with margin-to-bifurcation-distance (MTBD) ≤ 2.5 cm and pancreatic body and tail tumor with MTBD > 2.5 cm. The metastatic rate of the No. 9 LNs was compared among the 3 groups. The survival outcomes were analyzed. RESULTS The involvement rate for No. 9 LNs was 20.7% (6/29) for pancreatic neck tumors, 17.6% (15/85) for body and tail tumors with MTBD ≤ 2.5 cm and 1.8% (1/55) for MTBD > 2.5 cm. The No. 9 LNs were significantly more frequently involved in neck or body and tail tumors with MTBD ≤2.5 cm than with the cases with MTBD >2.5 cm (OR 0.082, P = 0.016). No. 9 LN involvement was not associated with worse survival compared with survival associated with involvement of other LNs (P = 0.780). CONCLUSIONS For PDAC located in the neck or in the body and tail of the pancreas with MTBD ≤ 2.5 cm, the involvement rate for No. 9 LNs is high. Standard lymphadenectomy should include the No. 9 LNs.
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Affiliation(s)
- Yiran Zhou
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Jiewei Lin
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Wei Wang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Hao Chen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chenghong Peng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Dongfeng Cheng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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Sivasanker M, Desouza A, Bhandare M, Chaudhari V, Goel M, Shrikhande SV. Radical antegrade modular pancreatosplenectomy for all pancreatic body and tail tumors: rationale and results. Langenbecks Arch Surg 2019; 404:183-190. [PMID: 30790046 DOI: 10.1007/s00423-019-01763-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/07/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) has been propagated as the standard of care for pancreatic cancers involving the body and tail of the pancreas. This procedure has been shown to have promising results in enhancing the microscopically negative tangential resection margins as well as the lymph node yield. METHODS This is a retrospective analysis of prospectively maintained database on the resections performed for all pancreatic body and tail tumors at Tata Memorial Centre. RESULTS Sixty-five patients underwent RAMPS without any perioperative mortality. The various pathologies comprised of adenocarcinoma (41.5%), neuroendocrine tumors (12.3%), solid pseudopapillary epithelial neoplasm (15.3%), cystic neoplasms (15.2%), etc. The R0 resection rate was 87.7%. Among this cohort, 27 patients had pancreatic adenocarcinoma. The 3-year OS and DFS for distal pancreatic cancers were 56% and 38%, respectively, but 3-year OS and DFS for other distal pancreatic tumors were 97% and 73%, respectively. On multivariate analysis, R0 resection significantly improved disease-free survival (p = 0.023) for pancreatic cancer. CONCLUSION RAMPS procedure aids to achieve high negative tangential margins for all tumors involving the body and tail of the pancreas and not just pancreatic cancer in isolation. Since preoperative histologic diagnosis is not routinely indicated and also a number of other distal pancreatic tumors carry a relatively better prognosis compared with pancreatic cancer, our results provide further evidence that RAMPS should be considered as the procedure of choice for all operable tumors involving body and tail of the pancreas.
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Affiliation(s)
- Masillamany Sivasanker
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Ashwin Desouza
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Manish Bhandare
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Vikram Chaudhari
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Mahesh Goel
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India.
- Division of Cancer Surgery, Department of Gastrointestinal and HPB Surgery, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India.
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Watanabe G, Ito H, Sato T, Ono Y, Mise Y, Inoue Y, Takahashi Y, Saiura A. Left kidney mobilization technique during radical antegrade modular pancreatosplenectomy (RAMPS). Langenbecks Arch Surg 2019; 404:247-252. [PMID: 30810806 DOI: 10.1007/s00423-019-01767-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/18/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE Radical antegrade modular pancreatosplenectomy (RAMPS) has been accepted as a standard operation for distal pancreatic cancer. While enbloc retroperitoneal dissection in the "medial to lateral" direction is one of the most important steps in this oncologic procedure, it is technically challenging due to the depth of organs under the left costal margin, and poor exposure of the resecting organs in this area will increase the risk of incomplete oncologic dissection. METHODS To improve exposure of the left upper quadrant organs, left kidney was completely mobilized during RAMPS, and all the left upper quadrant organs were elevated and medialized by lap sponges packed in the retro-renal space. The operative and oncologic outcomes for patients who underwent our modified RAMPS with left kidney mobilization were evaluated. RESULTS One hundred and forty-four patients with distal pancreatic cancer underwent this procedure from 2005 through 2016. The median operation time was 310 min (range, 132-899), and blood loss was 440 ml (25-2430). There was no complication associated to left kidney mobilization. The median number of harvested lymph nodes was 27 (3-87). While 77% of the tumors had microscopic retroperitoneal invasion, 96% of patients achieved negative retroperitoneal margin. CONCLUSIONS Left kidney mobilization is useful for safe and oncologically sound lateral retroperitoneal dissection during RAMPS for distal pancreatic cancer.
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Affiliation(s)
- Genki Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Japanse Foundation for Cancer Research, Cancer Insitute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Surgery, Juntendo University Hospital, Hongo, Tokyo, Japan
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21
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Zhou Q, Fengwei-Gao, Gong J, Xie Q, Liu Y, Wang Q, Lei Z. Assessement of postoperative long-term survival quality and complications associated with radical antegrade modular pancreatosplenectomy and distal pancreatectomy: a meta-analysis and systematic review. BMC Surg 2019; 19:12. [PMID: 30691444 PMCID: PMC6348671 DOI: 10.1186/s12893-019-0476-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/15/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND This study evaluated the perioperative complications and the long-term pancreatic survival outcomes in patients treated with radical antegrade modular pancreatosplenectomy (RAMPS) and distal pancreatectomy (DP). METHOD We performed a computer search on the PubMed, Embase and Cochrane Library databases to retrieve the RCT or clinical trials comparing RAMPS and DP published before July of 2018. The quality of the included trials was assessed according to the inclusion and exclusion criteria by two researchers independently. The RevMan 5.3 software was used to extract and analyze the data. RESULT A total of 5 retroprospective clinical trial articles comprising 285 patients were included in the study. The number of patients who underwent RAMPS were 135 and 150 for DP. There were significant differences (P < 0.05) in the operation time [WMD = - 63.93, 95% CI (- 68.86 ~ - 58.99), P<0.00001], and bleeding volume [WMD = - 184.62, 95% CI (- 211.88 ~ - 157.37), P<0.00001] between the two groups. However, no significant differences were observed between RAMPS and DP in terms of pancreatic fistula, postoperative complications, postoperative hospital stay, and mortality (P>0. 05). As for pathological examination, there were statistically significant differences between RAMPS and DP in the R0 resection rate [RR = 2.37, 95% CI (1.19 ~ 4.72), P = 0.01] and the number of lymph node excision [WMD = 7.08, 95% CI (4.59 ~ 9.58), P<0.000013]. The one-year overall survival rate was higher in RAMPS patients compared to DP patients [RR = 1.20, 95% CI (1.02 ~ 1.41), P = 0.02]. But there were no significant difference in postoperative recurrence [RR = 0.85, 95% CI (0.70 ~ 1.04), P = 0.13] between the two groups. CONCLUSION RAMPS is an effective procedure for clinical application. Nevertheless, large, multicenter prospective randomized controlled trias are required to validate these findings. CONCLUSION The RAMPS procedure was associated with good postoperative outcomes and overall survival, indicating that it is an effective procedure for clinical application. Large, multicenter prospective randomized controlled trials are needed to validate these findings.
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Affiliation(s)
- Quanyu Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Fengwei-Gao
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Jie Gong
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Qingyun Xie
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Yu Liu
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Qing Wang
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
| | - Zehua Lei
- Department of Hepatobiliary and Pancreatic Surgery, The People’s Hospital of Leshan City, Leshan, Sichuan 614000 People’s Republic of China
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Klompmaker S, Boggi U, Hackert T, Salvia R, Weiss M, Yamaue H, Zeh HJ, Besselink MG. Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer. How I do It. J Gastrointest Surg 2018; 22:1804-1810. [PMID: 30105677 PMCID: PMC6153684 DOI: 10.1007/s11605-018-3894-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/20/2018] [Indexed: 01/31/2023]
Abstract
Approximately 30% of all pancreatic cancer patients have locally advanced (AJCC stage 3) disease. A sub-group of these patients-where the cancer only involves the celiac axis-may benefit from distal pancreatectomy with celiac axis resection (DP-CAR). Previous studies have shown that DP-CAR offers a survival benefit to a selected group of patients with otherwise unresectable pancreatic cancer, when performed by experienced pancreatic cancer treatment teams at high-volume centers. This article proposes a standardized approach to DP-CAR, including routine neoadjuvant (FOLFIRINOX) chemotherapy. This approach to selecting patients and performing DP-CAR has the potential to improve short-term outcomes and overall survival in selected patients, but it should be reserved for high-volume centers.
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Affiliation(s)
- Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Roberto Salvia
- Department of Surgery, University of Verona, Verona, Italy
| | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD USA
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Herbert J. Zeh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX USA
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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23
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Banerjee JK, Saranga Bharathi R, Singh P, Singh G, Soneji D. Synchronous Adenocarcinomas of Pancreatic Body and Gastro-Esophageal Junction: Management Strategy. J Gastrointest Cancer 2018; 49:186-189. [PMID: 27449647 DOI: 10.1007/s12029-016-9860-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jayant Kumar Banerjee
- Department of Gastrointestinal Surgery, Command Hospital (Southern Command), Pune, Maharashtra, 411040, India
| | - Ramanathan Saranga Bharathi
- Department of Gastrointestinal Surgery, Command Hospital (Southern Command), Pune, Maharashtra, 411040, India.
| | - Pragnya Singh
- Department of Pathology, Command Hospital (Southern Command), Pune, Maharashtra, 411040, India
| | - Giriraj Singh
- Department of Radiology, Command Hospital (Southern Command), Pune, Maharashtra, 411040, India
| | - Dharmesh Soneji
- Department of Oncology, Command Hospital (Southern Command), Pune, Maharashtra, 411040, India
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Radiologic evaluation of patients undergoing the modified Appleby procedure for locally advanced pancreatic neoplasms: a case series. Abdom Radiol (NY) 2018; 43:467-475. [PMID: 29022090 DOI: 10.1007/s00261-017-1344-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Despite advances in medical and surgical care, pancreatic ductal adenocarcinoma remains one of the most locally aggressive neoplastic processes in the abdomen. Unfortunately, most pancreatic adenocarcinomas present late and are unresectable at time of diagnosis. The modified Appleby procedure is a surgical option in patients with locally advanced pancreatic neoplasms of the body and tail with vascular invasion of the celiac trunk. To our knowledge, no radiologic journal has previously reported on the pre-operative evaluation or postoperative imaging findings of such patients. METHODS We report herein three patients who underwent the modified Appleby procedure, each with a unique complication, in an attempt to illustrate common pitfalls of interpretation in these advanced cases. RESULTS Our case series emphasizes the importance of pre-operative radiologic assessment of variant arterial anatomy, knowledge of pre- and intraoperative procedures and appearances, and familiarity with potential postoperative complications. CONCLUSIONS Thorough understanding of the important aspects of the pre-surgical anatomy, as well as possible post-surgical complications, is the key to the radiologist being a useful participant in the clinical care of these patients.
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25
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Lee H, Heo JS, Choi SH, Choi DW. Extended versus peripancreatic lymph node dissection for the treatment of left-sided pancreatic cancer. Ann Surg Treat Res 2017; 92:411-418. [PMID: 28580345 PMCID: PMC5453873 DOI: 10.4174/astr.2017.92.6.411] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/05/2016] [Accepted: 01/16/2017] [Indexed: 01/16/2023] Open
Abstract
Purpose The pathways of lymphatic metastases differ according to the tumor location in pancreatic cancer patients. However, it is unclear whether extended lymph node dissection (LND) is essential for all left-sided pancreatic cancer. The aim of this study is to evaluate the survival outcomes according to the extent of LND and tumor location in patients with left-sided pancreatic cancer. Methods January 2005 to December 2013, we retrospectively identified 107 patients who underwent curative intent surgery for left-sided pancreatic cancer. The left-sided pancreatic cancer was defined as a tumor located in pancreatic body or tail. The extent of LND was divided into 2 groups: extended LND and peripancreatic LND. The extended LND group included celiac and superior mesenteric LNs. Results We included 107 patients with left-sided pancreatic cancer; 59 patients with pancreatic body cancer and 48 patients with pancreatic tail cancer. The median follow-up period was 17 months (range, 3–110 months). Fifty patients with pancreatic body cancer and 30 patients with pancreatic tail cancer underwent extended LND. In patients with pancreatic body cancer, extended LND was associated with improved disease-free survival (DFS) (P = 0.010) and overall survival (P = 0.014). However, extended LND was not associated with DFS in patients with pancreatic tail cancer. Conclusion Extended LND could improve survival in patients with pancreatic body cancer. However, extended LND had no survival benefit for the treatment of pancreatic tail cancer.
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Affiliation(s)
- Huisong Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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26
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Seo JW, Hwang HK, Lee M, Kim KW, Kang CM, Kim MJ, Chung YE. Normal Postoperative Computed Tomography Findings after a Variety of Pancreatic Surgeries. Korean J Radiol 2017; 18:299-308. [PMID: 28246510 PMCID: PMC5313518 DOI: 10.3348/kjr.2017.18.2.299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreatic surgery remains the only curative treatment for pancreatic neoplasms, and plays an important role in the management of medically intractable diseases. Since the original Whipple operation in the 20th century, surgical techniques have advanced, resulting in decreased postoperative complications and better clinical outcomes. Normal postoperative imaging findings vary greatly depending on the surgical technique used. Radiologists are required to be familiar with the normal postoperative imaging findings, in order to distinguish from postoperative complications or tumor recurrence. In this study, we briefly review a variety of surgical techniques for the pancreas, and present the normal postoperative computed tomography findings.
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Affiliation(s)
- Ji Won Seo
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Minwook Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ki Whang Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Myeong-Jin Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
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27
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Cienfuegos JA, Salguero J, Núñez-Córdoba JM, Ruiz-Canela M, Benito A, Ocaña S, Zozaya G, Martí-Cruchaga P, Pardo F, Hernández-Lizoáin JL, Rotellar F. Short- and long-term outcomes of laparoscopic organ-sparing resection in pancreatic neuroendocrine tumors: a single-center experience. Surg Endosc 2017; 31:3847-3857. [DOI: 10.1007/s00464-016-5411-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 12/30/2016] [Indexed: 02/06/2023]
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28
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Kim EY, Hong TH. Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer in a single institution: technical aspects and oncological outcomes. BMC Surg 2017; 17:2. [PMID: 28061895 PMCID: PMC5219804 DOI: 10.1186/s12893-016-0200-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/24/2016] [Indexed: 12/30/2022] Open
Abstract
Background Laparoscopic surgery has been performed less frequently in the era of pancreatic cancer due to technical difficulties and concerns about oncological safety. Radical antegrade modular pancreatosplenectomy (RAMPS) is expected to be helpful to obtain a negative margin during radical lymph node dissection. We hypothesized that it would also be favorable as a laparoscopic application due to unique features. Methods Fifteen laparoscopic RAMPS for well-selected patients with left-sided pancreatic cancer were performed from July 2011 to April 2016. Five trocars were usually used, and the operative procedures and range of dissection were similar to or the same as those of open RAMPS described by Strasberg. All medical records and follow-up data were reviewed and analyzed. Results All patients had pancreatic ductal adenocarcinoma. Mean operative time was 219.3 ± 53.8 min, and estimated blood loss was 250 ± 70 ml. The length of postoperative hospital stay was 6.1 ± 1.2 days, and postoperative morbidities developed in two patients (13.3%) with urinary retention. The median number of retrieved lymph nodes was 18.1 ± 6.2 and all had negative margins. Median follow-up time was 46.0 months, and the 3-year disease free survival and overall survival rates were 56.3% and 74.1%, respectively. Conclusion Our early experience with laparoscopic RAMPS achieved feasible perioperative results accompanied by acceptable survival outcomes. Laparoscopic RAMPS could be a safe and oncologically feasible procedure in well-selected patients with left-sided pancreatic cancer.
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Affiliation(s)
- Eun Young Kim
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Tae Ho Hong
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Pucci MJ, Kennedy EP, Yeo CJ. Pancreatic cancer. BLUMGART'S SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS, 2-VOLUME SET 2017:979-987.e2. [DOI: 10.1016/b978-0-323-34062-5.00062-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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30
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Salman B, Yilmaz TU, Dikmen K, Kaplan M. Laparoscopic distal pancreatectomy. J Vis Surg 2016; 2:141. [PMID: 29078528 DOI: 10.21037/jovs.2016.07.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 07/18/2016] [Indexed: 12/24/2022]
Abstract
After technological advances and increased experiences, more complicated surgeries including distal pancreatectomy can be easily performed with acceptable oncologic results, and decreased mortality and morbidity. Laparoscopic distal pancreatectomy (LDP) has been shown to have several advantages including less blood loss, less hospital stay, less pain. Several studies comparing open distal pancreatectomy (ODP) and LDP resulted that both techniques have similar results according to pancreas fistulas, oncological results, costs and operation indications. Morbidity is very low in high volume centers, for this reason at least ten cases should be performed for the learning curve. Several authors remarked important technical points in LDP in order to perform safe and acceptable LDP in several studies. Here in this review, we aimed to overview the results of previous studies about LDP and discuss the technical points of LDP.
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Affiliation(s)
- Bulent Salman
- Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey
| | - Tonguc Utku Yilmaz
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Kursat Dikmen
- Department of General Surgery, Gazi University School of Medicine, Ankara, Turkey
| | - Mehmet Kaplan
- Department of General Surgery, Bahcesehir University School of Medicine, Istanbul, Turkey
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31
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Kim EY, You YK, Kim DG, Hong TH. Initial experience with radical antegrade modular pancreatosplenectomy in a single institution. Ann Surg Treat Res 2016; 91:29-36. [PMID: 27433462 PMCID: PMC4942536 DOI: 10.4174/astr.2016.91.1.29] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/12/2016] [Accepted: 05/02/2016] [Indexed: 12/17/2022] Open
Abstract
Purpose Radical antegrade modular pancreatosplenectomy (RAMPS) is expected to be favorable for obtaining the negative tangential margin with oncologic feasibility through the horizontal dissection in a right-to-left fashion for radical lymph node dissections. Methods From January 2007 to February 2015, a total of 30 RAMPS and 19 conventional distal pancreatectomy (DP) cases were enrolled. The demographics, perioperative and survival outcomes were compared according to the type of surgery. Results The mean operative time, blood loss and length of hospital stay were similar between 2 groups. Morbidities were reported in 14 cases of RAMPS (46.7%) and 8 cases of DP (42.1%) (P = 0.777). The rate of negative tangential margin (96.2%) and the number of harvested lymph nodes (mean ± standard deviation, 21.5 ± 8.3) were significantly higher in RAMPS group (P = 0.011, P = 0.003, respectively). In terms of survival outcomes, there was no significant difference in regard to the overall 3-year disease-free survival (DFS; 30.4% in RAMPS vs. 35.0% in DP, P = 0.354) or overall survival (OS; 29.9% vs. 29.4%, P = 0.429) between the 2 groups. After exclusion of cases with nodal invasion, however, the RAMPS group had a longer DFS than the DP group (55.6% vs. 27.3%, P = 0.048) although OS was similar without significant difference (42.4% vs. 27.3%, P = 0.197). Conclusion RAMPS is a safe and oncologically feasible procedure in left-sided pancreatic cancer by obtaining a successful negative tangential margin and radical lymph node dissection. The authors suggest it could also be useful for local control, especially for the limited left-sided pancreatic cancer without nodal invasion.
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Affiliation(s)
- Eun Young Kim
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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32
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Grossman JG, Fields RC, Hawkins WG, Strasberg SM. Single institution results of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of pancreas in 78 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:432-41. [PMID: 27207482 DOI: 10.1002/jhbp.362] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/19/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The purpose of this report is to present results of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure in 78 patients from a single center. METHODS Seventy-eight patients had RAMPS procedure over 13 years. A database dealing with RAMPS for adenocarcinoma of the pancreas was constructed so that it could be converted into a set of tables. Each table covered one element of the subject. The database was populated from clinical records of patients who had a RAMPS procedure from 1999 to 2013. RESULTS Fifty-six patients had anterior RAMPS and 22 had posterior RAMPS. Negative tangential margins were obtained in 94% of specimens. Overall the R0 rate was 85%. Mean lymph node count was 20. There were no 30-day or in-hospital mortalities but two patients died within 90 days. Pancreatic fistula and need for postoperative transfusion were the most common complications. Median survival was 24.6 months and 5-year overall actuarial survival was 25.1%. CONCLUSIONS The RAMPS technique resulted in high negative tangential margin rates and good lymph node retrieval. The long-term survival result in 78 patients is probably an accurate reflection of what is possible with this tumor using this technique at this time.
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Affiliation(s)
- Julie G Grossman
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - Ryan C Fields
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
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Morris M, Price T, Callahan Z, Yeo CJ. Celiac Axis Resection with Distal Pancreatectomy (Modified Appleby Procedure) Allows for R0 Resection of Pancreatic Body and Tail Mass Following Neoadjuvant Therapy: Case Report and Literature Review. Case Rep Pancreat Cancer 2016; 2:53-57. [PMID: 30631817 PMCID: PMC6319680 DOI: 10.1089/crpc.2016.0011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: The modified Appleby procedure has been developed for cancer of the pancreatic body or tail with celiac axis invasion, historically classified as unresectable disease. Post-Appleby resection, the source of arterial blood to the liver is the superior mesenteric artery, which supplies the gastroduodenal artery and ultimately feeds the proper hepatic artery. In cases of inadequate collateralization, preoperative coiling of the common hepatic artery (CHA) or intraoperative reconstruction via an aorto-hepatic bypass has been described. Method: We describe a 74-year-old female with a pancreatic mass that was initially determined to be unresectable. She underwent extensive combination neoadjuvant chemotherapy. A favorable response was evidenced by a decrease in serum CA 19-9 levels. After 7 months, she was restaged and offered a distal pancreatectomy (DP) with the possibility of a modified Appleby procedure due to potential tumor involvement of the proximal CHA. Results: Intraoperatively, tumor was identified along the CHA traveling proximally to the celiac axis. Therefore, a modified Appleby procedure with DP and splenectomy was performed without the need for reconstruction of the CHA. Postoperative specimen pathology showed residual pancreatic ductal adenocarcinoma with marked treatment effects. The pathology confirmed an R0 resection. The patient followed our postpancreatic surgery care pathway. She remains well 7 months postoperatively. Conclusion: A pancreatic body or tail mass encasing the celiac vessels should not be an immediate referral for palliative care. Recent evidence shows that successful R0 resection can be achieved following neoadjuvant therapy. In fact, patients who have undergone a successful modified Appleby procedure show survival outcomes similar to patients with less advanced cancer who underwent standard DP. The modified Appleby procedure used in conjunction with neoadjuvant therapy can achieve complete resection in select patients previously thought to be unresectable.
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Affiliation(s)
- Mackenzie Morris
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Thea Price
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Zachary Callahan
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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de Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol 2016; 13:227-38. [PMID: 26882881 DOI: 10.1038/nrgastro.2016.17] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Laparoscopic surgery for benign and malignant pancreatic lesions has slowly been gaining acceptance over the past decade and is being introduced in many centres. Some studies suggest that this approach is equivalent to or better than open surgery, but randomized data are needed to assess outcomes. In this Review, we aim to provide a comprehensive overview of the state of the art in laparoscopic pancreatic surgery by aggregating high-quality published evidence. Various aspects, including the benefits, limitations, oncological efficacy, learning curve and latest innovations, are discussed. The focus is on laparoscopic Whipple procedure and laparoscopic distal pancreatectomy for both benign and malignant disease, but robot-assisted surgery is also addressed. Surgical and oncological outcomes are discussed as well as quality of life parameters and the cost efficiency of laparoscopic pancreatic surgery. We have also included decision-aid algorithms based on the literature and our own expertise; these algorithms can assist in the decision to perform a laparoscopic or open procedure.
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Affiliation(s)
- Thijs de Rooij
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor of the digestive system with a high degree of malignancy, accounting for about 90% of cases of pancreatic cancer. It has an occult onset and progresses rapidly, with a poor treatment effect and prognosis. It is one of malignant tumors with the worst prognosis. Surgical resection, as the only effective treatment, can be performed in only 20%-30% of patients, and the average period of survival after surgery is still less than 2 years. The main treatment strategy for PDAC are surgery-based individualized treatment modalities under comprehensive multidisciplinary collaboration. Currently, the therapeutic effect on pancreatic cancer is still not satisfactory. In recent years, various treatments for PDAC is becoming a hot spot of research. This article reviews the progress in the treatment of PDAC in terms of radical surgery, palliative surgery, adjuvant therapy, and other treatment opinions.
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36
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Hackert T, Ulrich A, Büchler MW. Borderline resectable pancreatic cancer. Cancer Lett 2016; 375:231-237. [PMID: 26970276 DOI: 10.1016/j.canlet.2016.02.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 02/20/2016] [Accepted: 02/23/2016] [Indexed: 02/07/2023]
Abstract
Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20-25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications. The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.
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Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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Gall TMH, Tsakok M, Wasan H, Jiao LR. Pancreatic cancer: current management and treatment strategies. Postgrad Med J 2015; 91:601-7. [PMID: 26243882 DOI: 10.1136/postgradmedj-2014-133222] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 07/14/2015] [Indexed: 12/18/2022]
Abstract
The 5-year survival of patients with pancreatic cancer is poor and, despite oncological advances over the past two decades, has not significantly improved. However, there have been several surgical and oncological advances which have improved morbidity and mortality in surgery and more efficacious chemotherapy regimens, resulting in a better patient experience and an increase in survival by a number of months. Most patients have a tumour at the head of the pancreas and those with resectable disease undergo a pancreaticoduodenectomy, which can be performed laparoscopically. Those who have a pancreatic resection have an increased survival in comparison with those receiving oncological treatment only; however, only a quarter of patients have resectable disease at diagnosis. Some centres are now performing venous resections and/or arterial resections in order to increase the number of patients eligible for curative surgery. Innovative techniques using ablation technologies to downstage tumours for resection are also being investigated. After surgery, all patients should be offered adjuvant gemcitabine-based chemotherapy. Those with locally advanced tumours not suitable for surgery should be offered FOLFIRINOX chemotherapy, after which the tumour may be suitable for surgical resection. The use of radiotherapy in this group of patients is controversial but offered by a few centres. Patients with metastatic disease at diagnosis should also be offered FOLFIRINOX chemotherapy, which can improve survival by a few months. As our knowledge of the tumour biology of pancreatic cancer progresses, a number of new agents targeting specific genes and proteins are under investigation and there is hope that median survival will continue to improve over the next decade.
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Affiliation(s)
- Tamara M H Gall
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Maria Tsakok
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Harpreet Wasan
- Department of Oncology, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Long R Jiao
- HPB Surgical Unit, Department of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
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38
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Shakir M, Boone BA, Polanco PM, Zenati MS, Hogg ME, Tsung A, Choudry HA, Moser AJ, Bartlett DL, Zeh HJ, Zureikat AH. The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre. HPB (Oxford) 2015; 17:580-6. [PMID: 25906690 PMCID: PMC4474504 DOI: 10.1111/hpb.12412] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Robotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high-volume pancreatic centre. METHODS Metrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve. RESULTS Between 2008 and 2013, 100 patients underwent RDP. There was no 90-day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P < 0.0001). The likelihood of readmission was significantly lower after the first 40 cases (P = 0.04), and non-significant reductions were observed in incidences of major (Clavien-Dindo Grade II or higher) morbidity and Grade B and C leaks, and length of stay. CONCLUSIONS In this experience, RDP outcomes were optimized after 40 cases. Familiarity with the platform and dedicated training are likely to contribute to significantly shorter learning curves in future adopters.
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Affiliation(s)
- Murtaza Shakir
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Brian A Boone
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | | | - Mazen S Zenati
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Haroon A Choudry
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - A James Moser
- Department of Surgery, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - David L Bartlett
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
| | - Amer H Zureikat
- Department of Surgery, University of PittsburghPittsburgh, PA, USA
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Abstract
Distal pancreatic cancer is an aggressive malignancy with insidious and subtle presentation, low radical resection rate and poor prognosis. The effectiveness of treatments for this disease remains to be improved. Radical resection is the only curable treatment. Personalized therapeutic strategy with surgical resection as a core should be the standard mode for these patients, and a professional multidisciplinary team is indispensable. Patients with borderline resectable cancers may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to the resection. Radical antegrade modular pancreatosplenectomy (RAMPS) is designed to establish an operation with oncologic rationales and should be the standard radical resection mode for distal pancreatic cancer. The use of diagnostic laparoscopy can help find hepatic metastases and peritoneal dissemination to avoid an unnecessary open operation. Laparoscopic distal pancreatectomy has many advantages compared with open operation, but is only applicable to early-stage patients with small tumors. In addition, the long-term oncologic effects of this surgical procedure still need to be verified, and it should be carried out selectively. Radical distal (or left) pancreatectomy with resection of the celiac axis (DP-CAR) is proper for some patients with evidence of celiac arterial invasion and should be conducted meticulously. However, new breakthroughs in early diagnosis and genetically personalized therapy are urgently needed. We still need prospective, randomized studies in multicenter institutions to provide more evidence for the neoadjuvant approach and laparoscopic distal pancreatectomy.
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40
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Abstract
Distal pancreatectomy is the standard procedure for tumors located in the body and tail of the pancreas. In the last three decades, significant progress has been made with regard to technical aspects as well as perioperative care so that excellent mortality and morbidity rates can be achieved. Recently, there is growing evidence that distal pancreatectomy may be performed laparoscopically in selected patients, offering the advantages of minimally invasive surgery. Unfortunately, the oncologic outcomes for pancreatic adenocarcinoma remain poor, in part due to the late stage of presentation in most patients. We review the history of distal pancreatectomy, discuss current indications for performing this procedure, compare operative techniques in performing distal pancreatectomy, and review both the early complications seen in patients who have undergone a distal pancreatectomy and the long-term metabolic and oncologic outcomes of these patients.
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Affiliation(s)
- Purvi Y Parikh
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY
| | - Keith D Lillemoe
- Harvard Medical School, Massachusetts General Hospital, Boston, MA.
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41
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Björnsson B, Sandström P. Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas. World J Gastroenterol 2014; 20:13402-13411. [PMID: 25309072 PMCID: PMC4188893 DOI: 10.3748/wjg.v20.i37.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 02/11/2014] [Accepted: 04/23/2014] [Indexed: 02/07/2023] Open
Abstract
Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.
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Ouaïssi M, Silvy F, Loncle C, Ferraz da Silva D, Martins Abreu C, Martinez E, Berthézene P, Cadra S, Le Treut YP, Hardwigsen J, Sastre B, Sielezneff I, Benkoel L, Delgrande J, Ouaissi A, Iovanna J, Lombardo D, Mas E. Further characterization of HDAC and SIRT gene expression patterns in pancreatic cancer and their relation to disease outcome. PLoS One 2014; 9:e108520. [PMID: 25275504 PMCID: PMC4183483 DOI: 10.1371/journal.pone.0108520] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/24/2014] [Indexed: 01/26/2023] Open
Abstract
Ductal adenocarcinoma of the pancreas is ranking 4 for patient' death from malignant disease in Western countries, with no satisfactory treatment. We re-examined more precisely the histone deacetylases (HDAC) and Sirtuin (SIRT) gene expression patterns in pancreatic cancer with more pancreatic tumors and normal tissues. We also examined the possible relationship between HDAC gene expression levels and long term disease outcome. Moreover, we have evaluated by using an in vitro model system of human pancreatic tumor cell line whether HDAC7 knockdown may affect the cell behavior. We analyzed 29 pancreatic adenocarcinoma (PA), 9 chronic pancreatitis (CP), 8 benign pancreatic (BP) and 11 normal pancreatic tissues. Concerning pancreatic adenocarcinoma, we were able to collect biopsies at the tumor periphery. To assess the possible involvement of HDAC7 in cell proliferation capacity, we have generated recombinant human Panc-1 tumor which underexpressed or overexpressed HDAC7. The expression of HDAC1,2,3,4,7 and Nur77 increased in PA samples at levels significantly higher than those observed in the CP group (p = 0.0160; 0.0114; 0.0227; 0.0440; 0.0136; 0.0004, respectively). The expression of HDAC7, was significantly greater in the PA compared with BP tissue samples (p = 0.05). Mean mRNA transcription levels of PA for HDAC7 and HDAC2 were higher when compared to their counterpart biopsies taken at the tumor periphery (p = 0.0346, 0.0053, respectively). Moreover, the data obtained using confocal microscopy and a quantitative method of immunofluorescence staining strongly support the HDAC7 overexpression in PA surgical specimens. The number of deaths and recurrences at the end of follow up were significantly greater in patients with overexpression of HDAC7. Interestingly, the rate of growth was significantly reduced in the case of cell carrying shRNA construct targeting HDAC7 encoding gene when compared to the parental Panc-1 tumor cells (p = 0.0015) at 48 h and 96 h (p = 0.0021). This study strongly support the notion that HDAC7play a role in pancreatic adenocarcinoma progression.
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Affiliation(s)
- Mehdi Ouaïssi
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
- AP-HM, Timone Hospital, Department of Digestive and visceral Surgery, Marseille, France
| | - Françoise Silvy
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
| | - Céline Loncle
- Aix-Marseille University, CRCM, UMR_S 1068, Institut Paoli-Calmettes, CNRS, UMR7258, Marseille, France
- INSERM, UMR 1068, Marseille, France
| | - Diva Ferraz da Silva
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
- Faculdade de Farmácia da Universidade do Porto, Porto, Portugal
| | - Carla Martins Abreu
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
- Faculdade de Farmácia da Universidade do Porto, Porto, Portugal
| | - Emmanuelle Martinez
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
| | - Patrick Berthézene
- Aix-Marseille University, CRCM, UMR_S 1068, Institut Paoli-Calmettes, CNRS, UMR7258, Marseille, France
- INSERM, UMR 1068, Marseille, France
| | - Sophie Cadra
- Aix-Marseille University, CRCM, UMR_S 1068, Institut Paoli-Calmettes, CNRS, UMR7258, Marseille, France
- INSERM, UMR 1068, Marseille, France
| | - Yves Patrice Le Treut
- AP-HM, La Conception Hospital, Department of hepatic transplantation and general surgery, Marseille, France
- Aix-Marseille University, Marseille, France
| | - Jean Hardwigsen
- AP-HM, La Conception Hospital, Department of hepatic transplantation and general surgery, Marseille, France
- Aix-Marseille University, Marseille, France
| | - Bernard Sastre
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
- AP-HM, Timone Hospital, Department of Digestive and visceral Surgery, Marseille, France
| | - Igor Sielezneff
- AP-HM, Timone Hospital, Department of Digestive and visceral Surgery, Marseille, France
- Aix-Marseille University, Marseille, France
| | | | - Jean Delgrande
- AP-HM, Timone Hospital, Department of histopathology, Marseille, France
| | - Ali Ouaissi
- Faculdade de Farmácia da Universidade do Porto, Porto, Portugal
| | - Juan Iovanna
- Aix-Marseille University, CRCM, UMR_S 1068, Institut Paoli-Calmettes, CNRS, UMR7258, Marseille, France
- INSERM, UMR 1068, Marseille, France
| | - Dominique Lombardo
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
| | - Eric Mas
- Aix-Marseille University, CRO2, UMR_S 911, Marseille, France
- INSERM UMR 911, Marseille, France
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Splenic artery use for arterial reconstruction in pancreatic surgery. Langenbecks Arch Surg 2014; 399:667-71. [PMID: 24789810 DOI: 10.1007/s00423-014-1200-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/21/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extended resections in the upper GI tract, especially for pancreatic malignancies, can require resection of the hepatic or superior mesenteric artery. Besides venous or allogenous grafting, the splenic artery can be used for reconstruction in both positions. PURPOSE We hereby describe the different technical possibilities of interposition or transposition to use the splenic artery for restoration of arterial perfusion of the liver or the small bowel following resection of the hepatic or superior mesenteric artery, respectively. CONCLUSION The use of the splenic artery is a convenient and appropriate possibility to reconstruct the hepatic or superior mesenteric artery in pancreatic resection with regard to interposition and especially transposition of this vessel. It should be considered in patients suitable to undergo these procedures to extend resectability in pancreatic cancer surgery.
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