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de Liguori Carino N, Baltatzis M, Maroso F, Spiers HVM, Deshpande R, Jamdar S, Satyadas T, Sheen AJ, Siriwardena AK, O'Reilly DA. A fast-track surgery programme leads to timelier treatment and higher resection rates in pancreatic cancer. HPB (Oxford) 2022; 24:893-900. [PMID: 34802941 DOI: 10.1016/j.hpb.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/09/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting and an intention to treat analysis of long-term survival between the two groups. METHODS This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019. RESULTS In this study of 216 consecutive operable patients, 70 followed the fast-track pathway and 146 had pre-operative biliary drainage. All 70 patients in the FT group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was shorter in the FT group, (median 8 vs 43 days p < 0.001 and 3 vs 36 days p < 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p < 0.001). Postoperative outcomes including complications, readmission and mortality rates were comparable in the two groups. There was no difference in survival. CONCLUSION For a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage.
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Affiliation(s)
- Nicola de Liguori Carino
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Fabio Maroso
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Harry V M Spiers
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Rahul Deshpande
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Thomas Satyadas
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Centre for Biomedicine, Manchester Metropolitan University, Manchester, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Derek A O'Reilly
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK; Faculty of Biology, Health and Life Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.
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Sugara M, Peruvaje V, Krishnamurthy S, Kumar KVV, Chowdappa R. Effect of Preoperative Biliary Stenting on Outcomes of Pancreaticoduodenectomy. Indian J Surg Oncol 2021; 12:554-560. [PMID: 34658585 DOI: 10.1007/s13193-021-01387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022] Open
Abstract
Biliary drainage before pancreaticoduodenectomy was introduced to decrease morbidity from obstructive jaundice. Recent retrospective and randomised data show that preoperative biliary drainage (PBD) increases perioperative infectious complications. Most patients presenting to our tertiary care centre have undergone drainage procedures prior to surgical consultation. We analysed the impact of PBD, specifically endoscopic stent placement, on the postoperative outcome of pancreaticoduodenectomy at our centre. A cohort of 87 patients undergoing pancreaticoduodenectomy from 2012 to 2016 was identified. Data was collected retrospectively and a comparative analysis of stented and nonstented patients was done. Comparison of the 23 stented patients was done with 23 nonstented patients after matching them for age, sex and bilirubin levels. Median total bilirubin level in stented patients was 10.2 mg/dl versus 7.7 mg/dl in nonstented patients. The infectious complication rate in the stented group was 39.1% versus 12.7% in the nonstented group (P value < 0.05). There was no difference in the anastomotic leak rate between the two groups. Time to curative surgery in the stented group was significantly more than in the nonstented group. Stented patients are at a higher risk for postoperative infectious complications. Patients with obstructive jaundice awaiting surgery should undergo selective biliary drainage after careful planning and discussion between the operating surgeon and the endoscopist.
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Affiliation(s)
- Medha Sugara
- Department of Surgical Oncology, St. John's Medical College, Bengaluru, Karnataka 560034 India
| | - Vijay Peruvaje
- Department of ENT, Mandya Institute of Medical Sciences, Mandya, 571401 India
| | - S Krishnamurthy
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka 560029 India
| | - K V Veerendra Kumar
- Department of Surgical Oncology, Jawaharlal Nehru Medical College, Belgaum, Karnataka 590010 India
| | - Ramachandra Chowdappa
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka 560029 India
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Blacker S, Lahiri RP, Phillips M, Pinn G, Pencavel TD, Kumar R, Riga AT, Worthington TR, Karanjia ND, Frampton AE. Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer? Expert Rev Gastroenterol Hepatol 2021; 15:855-863. [PMID: 34036856 DOI: 10.1080/17474124.2021.1915127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.
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Affiliation(s)
- Sarah Blacker
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajiv P Lahiri
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Mary Phillips
- Dept. Of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Graham Pinn
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim D Pencavel
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajesh Kumar
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Angela T Riga
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim R Worthington
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Nariman D Karanjia
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Adam E Frampton
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.,Dept. Of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, the Leggett Building, University of Surrey, Guildford, Surrey, UK
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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