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Grewal M, Habib JR, Paluszek O, Cohen SM, Wolfgang CL, Javed AA. The Role of Intraoperative Pancreatoscopy in the Surgical Management of Intraductal Papillary Mucinous Neoplasms: A Scoping Review. Pancreas 2024; 53:e280-e287. [PMID: 38277399 DOI: 10.1097/mpa.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
OBJECTIVES Most patients with intraductal papillary mucinous neoplasms (IPMNs) are diagnosed with a solitary lesion; however, the presence of skip lesions, not appreciable on imaging, has been described. Postoperatively, these missed lesions can continue to grow and potentially become cancerous. Intraoperative pancreatoscopy (IOP) may facilitate detection of such skip lesions in the remnant gland. The aim of this scoping review was to appraise the evidence on the role of IOP in the surgical management of IPMNs. MATERIALS AND METHODS Studies reporting on the use of IOP during IPMN surgery were identified through searches of the PubMed, Embase, and Scopus databases. Data extracted included IOP findings, surgical plan modifications, and patient outcomes. The primary outcome of interest was the utility of IOP in surgical decision making. RESULTS Ten studies reporting on the use of IOP for IPMNs were identified, representing 147 patients. A total of 46 skip lesions were identified by IOP. Overall, surgical plans were altered in 37% of patients who underwent IOP. No IOP-related complications were reported. CONCLUSIONS The current literature suggests a potential role of integration of IOP into the management of patients with IPMNs. This tool is safe and feasible and can result in changes in surgical decision making.
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Affiliation(s)
- Mahip Grewal
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Joseph R Habib
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | | | - Steven M Cohen
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Christopher L Wolfgang
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Ammar A Javed
- From the Department of Surgery, New York University Grossman School of Medicine, New York, NY
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Hong S, Ren J, Zhang S, Yan Y, Liu S, Qi F. Comparison of clinical outcomes and prognosis between total pancreatectomy and pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis. ANZ J Surg 2023; 93:2820-2827. [PMID: 37614050 DOI: 10.1111/ans.18653] [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: 06/15/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND To compare the clinical outcomes and prognosis of total pancreatectomy (TP) and pancreaticoduodenectomy (PD) for the treatment of pancreatic ductal adenocarcinoma (PDAC), and to explore the safety and indications of TP. METHODS A systematic search was conducted on PubMed, Web of Science, and Embase databases from January 1943 to March 2023 for literatures comparing TP and PD in the treatment of PDAC. The primary outcome was postoperative overall survival (OS), and secondary outcomes included surgery time, blood loss, readmission, hospital stay, perioperative mortality, and overall morbidity. Fixed-effect or random-effect models were selected based on heterogeneity, and odds ratio (OR), mean difference (MD), or hazard ratio (HR) with 95% confidence intervals (CI) were calculated. RESULTS A total of six studies involving 8396 patients were included in the meta-analysis. There was no statistically significant difference in OS after surgery between the two groups (HR = 1.08, 95% CI: 0.91-1.27; P = 0.38). The TP group had a longer surgery time (MD = 13.66, 95% CI: 4.57-22.75; P = 0.003) and more blood loss (MD = 133.17, 95% CI: 8.00-258.33; P = 0.04) than the PD group. There were no significant differences between the two groups in terms of hospital stay (MD = 0.09, 95% CI: -2.04 to 2.22; P = 0.93), readmission rate (OR = 1.39; 95% CI: 1.00-1.92; P = 0.05), perioperative mortality (OR = 1.29, 95% CI: 0.98-1.69; P = 0.07), and overall morbidity (OR = 0.80, 95% CI: 0.50-1.26; P = 0.33). CONCLUSION The surgical process of TP is relatively complex, but there is no difference in short-term clinical outcomes and OS compared to PD, making it a safe and reliable procedure. Indications and treatment outcomes for planned TP and salvage TP may differ, and more research is needed in the future for further classification and verification.
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Affiliation(s)
- Shengqian Hong
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Jiao Ren
- Department of Radiology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Sufang Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Yulou Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Shiqi Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Fuzhen Qi
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
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Fernandes EDSM, de Mello FPT, Braga EP, de Souza GO, Andrade R, Pimentel LS, Girão CL, Siqueira M, Moraes-Junior JMA, de Oliveira RV, Goldaracena N, Torres OJM. A more radical perspective on surgical approach and outcomes in pancreatic cancer-a narrative review. J Gastrointest Oncol 2023; 14:1964-1981. [PMID: 37720458 PMCID: PMC10502544 DOI: 10.21037/jgo-22-763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/30/2022] [Indexed: 09/19/2023] Open
Abstract
Background and Objective Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer. Methods We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included. Key Content and Findings As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes. Conclusions Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.
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Affiliation(s)
- Eduardo de Souza M. Fernandes
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Universitário Clementino Fraga Filho-UFRJ, Rio de Janeiro, RJ, Brazil
| | - Felipe Pedreira T. de Mello
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Eduardo Pinho Braga
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Gabrielle Oliveira de Souza
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
| | - Ronaldo Andrade
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Leandro Savattone Pimentel
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Camila Liberato Girão
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - Munique Siqueira
- Departament of Gastrointestinal and Transplant Surgery, São Lucas Copacabana Hospital-Rede Dasa, Rio de Janeiro, RJ, Brazil
- Department of Gastrointestinal and Transplant Surgery, Adventista Silvestre Hospital, Rio de Janeiro, RJ, Brazil
| | - José Maria A. Moraes-Junior
- Department of Hepatopancreatobiliary Surgery, São Domingos Hospital-Rede Dasa, São Luís, MA, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Presidente Dutra, São Luis, MA, Brazil
| | | | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Orlando Jorge M. Torres
- Department of Hepatopancreatobiliary Surgery, São Domingos Hospital-Rede Dasa, São Luís, MA, Brazil
- Department of Gastrointestinal and Transplant Surgery, Hospital Presidente Dutra, São Luis, MA, Brazil
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Olakowski M, Grudzińska E. Pancreatic head cancer - Current surgery techniques. Asian J Surg 2023; 46:73-81. [PMID: 35680512 DOI: 10.1016/j.asjsur.2022.05.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 05/20/2022] [Indexed: 12/24/2022] Open
Abstract
Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland.
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Brunner M, Krautz C, Weber GF, Grützmann R. [Better Therapy for Pancreatic Cancer through More Radical Surgery?]. Zentralbl Chir 2022; 147:173-187. [PMID: 35378558 DOI: 10.1055/a-1766-7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.Even if even more radical surgical approaches such as an "extended" lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an "existing limited prognosis". On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.
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Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Christian Krautz
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Georg F Weber
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
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Hussein MH, Toraih EA, Reisner A, Shihabi A, Al-Quaryshi Z, Borchardt J, Kandil E. Preoperative diabetes complicates postsurgical recovery but does not amplify readmission risk following pancreatic surgery. Gland Surg 2022; 11:663-676. [PMID: 35531107 PMCID: PMC9068538 DOI: 10.21037/gs-21-648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/26/2022] [Indexed: 05/14/2024]
Abstract
BACKGROUND Diabetes is a significant and prevalent medical condition associated with increased comorbidities, longer hospital length of stay, and higher healthcare costs. We aimed to assess the association between diabetes mellitus and postoperative outcomes following pancreatic surgeries. METHODS Records for patients with major elective pancreatic surgeries were retrieved retrospectively from the Nationwide Readmission Database (2010-2014). Association of diabetic status with postoperative complications, in-hospital mortality, length of stay (LOS), readmission rate, and hospital costs were investigated. Logistic regression and decision tree analyses were employed to predict adverse outcomes. RESULTS A total of 8,401 patients who had pancreatic surgery were included. They were categorized according to their diabetic diagnosis. Results showed that diabetic patients had a higher risk of postoperative complications compared to non-diabetics (OR: 1.27, 95% CI: 1.08-1.49, P=0.003). Bleeding and renal complications were the most significant. Uncontrolled diabetes significantly required a longer hospital stay (9.17±4.28 vs. 8.03±4.96 days, P=0.001), and incurred higher hospital costs ($34,171.04±$20,846.61 vs. $28,182.21±$24,070.27, P=0.001). After multivariate regression, no association was found with in-hospital mortality or readmission rates; however, diabetic patients' length of stay during readmission was increased at 30- and 90-day readmissions (P=0.004 and 0.007, respectively). CONCLUSIONS Among patients who underwent pancreatic surgery, those with diabetes had a higher rate of postoperative complications compared to non-diabetics. Additionally, diabetic patients had higher hospital charges and costs during primary admission. Initial analysis of patients with diabetes showed they had higher rates of 30- and 90-day readmissions, though this did not maintain significance after regression analysis. Exploring the mechanisms underlying this finding would aid in preventing postoperative complications and reducing healthcare costs.
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Affiliation(s)
- Mohammad Hosny Hussein
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman Ali Toraih
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
- Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Adin Reisner
- Tulane University, School of Medicine, New Orleans, LA, USA
| | - Areej Shihabi
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Zaid Al-Quaryshi
- Department of Otolaryngology – Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jeffrey Borchardt
- Department of Anesthesiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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Chaouch MA, Leon P, Cassese G, Aguilhon C, Khayat S, Panaro F. Total pancreatectomy with intraportal islet autotransplantation for pancreatic malignancies: a literature overview. Expert Opin Biol Ther 2021; 22:491-497. [PMID: 34747305 DOI: 10.1080/14712598.2022.1990261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION 'Brittle Diabetes' (BD) is a life-threatening metabolic complication after total pancreatectomy (TP). More than 500 Intraportal islet autotransplantation (IAT) have been performed to prevent this complication, with almost 70% insulin independence after 3 years. Even when insulin independence was not achieved, IAT successfully prevented severe hypoglycemia. Currently, preliminary results for oncologic situations are promising, but their oncological outcomes are still a matter of debate. AREAS COVERED We performed a bibliographic research of the last 25 years of data. Articles published in English in peer-reviewed journals were retained. In France, auto- and allo-islet transplantation was recently recognized as a valuable treatment for BD by the national health authority. While accepted for benign diseases, the risk of tumor spreading after IAT in oncologic situations is a source of concern. EXPERT OPINION Preliminary results of IAT in oncological situations are very encouraging. So far, there is no evidence of tumor dissemination. In our opinion, to overcome BD TP with IAT for resectable pancreatic malignancies in patients with a higher risk of postoperative pancreatic fistula and extended pancreatic cancers can be safely performed. Diagnosis of malignancy should not be considered as an exclusion criterion for IAT.
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Affiliation(s)
- Mohamed Ali Chaouch
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Piera Leon
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Gianluca Cassese
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France.,Department of Clinical Medicine and Surgery, Federico Ii University, Naples, Italy
| | - Caroline Aguilhon
- Division of Endocrinology, Diabetology and Clinical Nutrition, Montpellier University Hospital, Montpellier, France
| | - Salah Khayat
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
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Principe DR, Underwood PW, Korc M, Trevino JG, Munshi HG, Rana A. The Current Treatment Paradigm for Pancreatic Ductal Adenocarcinoma and Barriers to Therapeutic Efficacy. Front Oncol 2021; 11:688377. [PMID: 34336673 PMCID: PMC8319847 DOI: 10.3389/fonc.2021.688377] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, with a median survival time of 10-12 months. Clinically, these poor outcomes are attributed to several factors, including late stage at the time of diagnosis impeding resectability, as well as multi-drug resistance. Despite the high prevalence of drug-resistant phenotypes, nearly all patients are offered chemotherapy leading to modest improvements in postoperative survival. However, chemotherapy is all too often associated with toxicity, and many patients elect for palliative care. In cases of inoperable disease, cytotoxic therapies are less efficacious but still carry the same risk of serious adverse effects, and clinical outcomes remain particularly poor. Here we discuss the current state of pancreatic cancer therapy, both surgical and medical, and emerging factors limiting the efficacy of both. Combined, this review highlights an unmet clinical need to improve our understanding of the mechanisms underlying the poor therapeutic responses seen in patients with PDAC, in hopes of increasing drug efficacy, extending patient survival, and improving quality of life.
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Affiliation(s)
- Daniel R. Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, United States
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Murray Korc
- Department of Developmental and Cell Biology, University of California, Irvine, CA, United States
| | - Jose G. Trevino
- Department of Surgery, Division of Surgical Oncology, Virginia Commonwealth University, Richmond, VA, United States
| | - Hidayatullah G. Munshi
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Ajay Rana
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
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Hempel S, Oehme F, Tahirukaj E, Kolbinger FR, Müssle B, Welsch T, Weitz J, Distler M. More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021; 28:8309-8317. [PMID: 34169383 PMCID: PMC8590996 DOI: 10.1245/s10434-021-10292-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/27/2021] [Indexed: 11/24/2022]
Abstract
Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10292-8.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ermal Tahirukaj
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy-Arterial Resection, Arterial Divestment and Total Pancreatectomy. Cancers (Basel) 2021; 13:cancers13081818. [PMID: 33920314 PMCID: PMC8068970 DOI: 10.3390/cancers13081818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Aggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC. Abstract Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.
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11
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Xie D, Qian B, Yang J, Peng X, Li Y, Hu T, Lu S, Chen X, Han Y. Can Elderly Patients With Pancreatic Cancer Gain Survival Advantages Through More Radical Surgeries? A SEER-Based Analysis. Front Oncol 2020; 10:598048. [PMID: 33194764 PMCID: PMC7660699 DOI: 10.3389/fonc.2020.598048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Aims In recent years, the best treatment method for pancreatic cancer in elderly patients has remained controversial. Surgery is the main treatment modality for pancreatic cancer. This study aimed to determine whether elderly patients with pancreatic cancer can gain survival advantages through more active and radical surgical treatment and evaluate the best treatment method and potential prognostic factors. Methods From the Surveillance, Epidemiology, and End Results program (SEER) database, 10,557 elderly patients (aged ≥65 years) with pancreatic cancer were included as Cohort 1, and Propensity Score Matching (PSM) evaluation was performed to generate Cohort 2 (424 pairs). Overall Survival (OS) and Cause-Specific Survival (CSS) were determined using Kaplan-Meier survival curves, and differences were assessed using the Log-rank test. Multivariate logistic regression analysis and the forest plot of hazard ratio (HR) was made to assess the association between potential prognostic factors, including surgery and different surgical methods, and survival in elderly patients. Results We identified 10,557 eligible patients with pancreatic cancer, who formed Cohort 1. The total OS and CSS in the surgery group were significantly higher than those in the non-surgery group (P < 0.001). Age, stage (AJCC 8th), grade, lymph node metastasis, radiation, chemotherapy, and surgical methods were independent factors affecting the prognosis of elderly patients. In Cohort 2, Total pancreatectomy (Total PT) had the lowest risk ratio (HR = 0.31, P < 0.001) and longest median CSS (18.000 months), while Extension Total pancreatectomy (Ex-Total PT, HR = 0.34, P < 0.001) showed the lower median CSS (17.000 months) and median OS (14.000 months). Partial pancreatectomy (Partial PT, HR = 0.46, P < 0.001) showed the lowest median CSS (13.000 months) and median OS (12.000 months), although they were still higher than the median CSS (6.000 months) and median OS (5.000 months) in the non-surgery group. Conclusions Based on the SEER database, surgical treatment is an independent prognostic factor in elderly patients with pancreatic cancer. Compared with other surgical methods, Total PT can offer elderly patients the best survival advantages. However, Ex-Total PT, a more radical method, does not seem to be the best treatment option for the survival and benefit of elderly patients.
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Affiliation(s)
- Danna Xie
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Baolin Qian
- Department of Hepatobiliary Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jing Yang
- Department of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Xinya Peng
- Department of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Yinghua Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Teng Hu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Simin Lu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaojing Chen
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yunwei Han
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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The Safety and Feasibility of Enhanced Recovery after Surgery in Patients Undergoing Pancreaticoduodenectomy: An Updated Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7401276. [PMID: 32462014 PMCID: PMC7232716 DOI: 10.1155/2020/7401276] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/24/2020] [Indexed: 12/18/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary, evidence-based approach to care for surgical patients and aims at optimizing the perioperative management and outcomes. The ERAS approach was first implemented in colorectal surgery patients; however, the reported applications in pancreatoduodenectomy patients are limited. In recent years, studies on ERAS for patients undergoing pancreaticoduodenectomy have been published. The accumulation of new randomized controlled trials and high-quality case-control studies stimulated us to update the analysis. Our study comprehensively collected data to provide the best evidence summary for the clinic. Aim To evaluate the safety and feasibility of enhanced recovery after surgery in the perioperative management of pancreatoduodenectomy patients. Methods A systematic literature search of PubMed, Embase, and the Cochrane Library was performed up to July 2019. All randomized controlled trials and case-control studies that applied ERAS for patients undergoing pancreaticoduodenectomy were considered for inclusion in this study. The patients were divided into two groups: patients who received the ERAS perioperative management approach were defined as the ERAS group and patients who received the traditional perioperative management approach were defined as the control group. All statistical analyses were conducted using the Revman5.3 software, and the outcomes were calculated as odds ratios or weighted mean differences with their corresponding 95% confidence intervals. A funnel plot was created to assess publication bias. Subgroup and sensitivity analyses were performed to explore the sources of heterogeneity. Results A total of 20 studies involving 3613 patients (1914 patients in the ERAS group vs. 1699 patients in the control group) were included in this study. Among the 20 studies, 4 were randomized controlled trials, and 16 were case-control studies. The overall postoperative complication rate was significantly lower in the ERAS group (OR = 0.62, 95% CI: 0.53-0.74, P < 0.00001) than in the control group. In addition, the minor complication rate (Clavien-Dindo I-II) was also lower in the ERAS group (OR = 0.70, 95% CI: 0.58-0.86, P = 0.0005). The patients in the ERAS group had a lower incidence of delayed gastric emptying (OR = 0.51, 95% CI: 0.42-0.63, P < 0.00001) and shorter length of hospital stay (WMD = -4.27, 95% CI: -4.81~-3.73, P < 0.00001) than in the control group. The rates of pancreatic fistula (regardless of Grade A/B/C), wound infections, abdominal abscesses, readmission, reoperation, and morbidity were not significantly different between the two groups. Conclusion The ERAS approach is safe and effective in the perioperative management of patients undergoing pancreaticoduodenectomy and helps to accelerate the postoperative recovery and improve prognosis.
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