1
|
Fukuda K, Koyama K, Kyoden Y. Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report. Surg Case Rep 2024; 10:113. [PMID: 38714591 PMCID: PMC11076426 DOI: 10.1186/s40792-024-01914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/27/2024] [Indexed: 05/10/2024] Open
Abstract
BACKGROUND Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions. CASE PRESENTATION This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases. CONCLUSIONS The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.
Collapse
Affiliation(s)
- Kaito Fukuda
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan.
| | - Ken Koyama
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan
| | - Yusuke Kyoden
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan
| |
Collapse
|
2
|
Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
Collapse
Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
| |
Collapse
|
3
|
Loos M, Khajeh E, Mehrabi A, Kinny-Köster B, Al-Saeedi M, Berchtold C, Hoffmann K, Schneider M, Eslami P, Feisst M, Hinz U, Hackert T, Büchler MW. Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure. Ann Surg 2023; 278:e1210-e1215. [PMID: 36994724 DOI: 10.1097/sla.0000000000005866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR). BACKGROUND DP-CAR can be used in a selective group of patients to resect locally advanced pancreatic cancer involving the celiac axis or common hepatic artery without arterial reconstruction by preserving retrograde blood flow via the gastroduodenal artery to the liver and stomach. METHODS We analyzed all consecutive patients who had undergone DP-CAR between May 2003 and April 2022 at a tertiary hospital specialized in pancreatic surgery and present one of the largest single-center studies. RESULTS A total of 71 patients underwent DP-CAR. Additional venous resection (VR) of the mesenterico-portal axis was performed in 31 patients (44%) and multivisceral resection (MVR) in 42 patients (59%). Margin-free (R0) resection was achieved in 40 patients (56%). The overall 90-day mortality rate was 8.4% for the entire patient cohort. After a cumulated experience of 16 cases, the 90-day mortality dropped to 3.6% in the following 55 patients. Extended procedures with (+) additional MVR with or without (+/-) VR resulted in higher major morbidity (Clavien-Dindo ≥IIIB; standard DP-CAR: 19%; DP-CAR + MVR +/- VR: 36%) and higher 90-day mortality (standard DP-CAR: 0%; DP-CAR + MVR +/- VR: 11%). Median overall survival after DP-CAR was 28 months. CONCLUSIONS DP-CAR is a safe and effective procedure but requires experience. Frequently, surgical resection has to be extended with MVR and VR to accomplish tumor resection, which results in promising oncologic outcomes. However, extended resections were associated with increased morbidity and mortality.
Collapse
Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Benedict Kinny-Köster
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Pegah Eslami
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute for Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
4
|
Sindayigaya R, Barat M, Tzedakis S, Dautry R, Dohan A, Belle A, Coriat R, Soyer P, Fuks D, Marchese U. Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist. Diagn Interv Imaging 2023; 104:455-464. [PMID: 37301694 DOI: 10.1016/j.diii.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.
Collapse
Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Anthony Dohan
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Romain Coriat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Philippe Soyer
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Ugo Marchese
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| |
Collapse
|
5
|
Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
Collapse
Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | | |
Collapse
|
6
|
Yoon SJ, Park SJ, Yoon YS, Hong TH, Jang JY, Kim HJ, Heo JS, Hwang DW, Han IW. 15-Year Experience of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer-A Korean Nationwide Investigation. Cancers (Basel) 2023; 15:3850. [PMID: 37568666 PMCID: PMC10417433 DOI: 10.3390/cancers15153850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND As systemic treatment for pancreatic cancer advances, distal pancreatectomy with celiac axis resection (DP-CAR) has been considered a curative-intent surgical option for advanced pancreatic cancer. This study aimed to review the surgical and oncologic outcomes of patients undergoing DP-CAR based on Korean nationwide data. METHODS We collected the data of patients who underwent DP-CAR for pancreatic cancer between 2007 and 2021 at seven major hospitals in Korea. The clinicopathological characteristics, postoperative complications, and data on the survival of the patients were retrospectively reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications and survival. RESULTS A total of 75 patients, consisting mainly of borderline resectable (n = 32) or locally advanced (n = 30) pancreatic cancer, were included in the analysis. Forty-two (56.0%) patients underwent neoadjuvant treatment (NAT). Twenty (26.7%) patients experienced Clavien-Dindo grade ≥ 3 complications, including four patients with ischemic gastropathy, two with hepatic ischemia, and two procedure-related mortalities. Neoadjuvant chemotherapy increased the risk of postoperative complications (p = 0.028). The median recurrence-free and overall survival were 7 and 19 months, with a 5-year survival rate of 13% and 24%, respectively. In the NAT group, a decrease in CA 19-9 and the post-NAT maximum standardized uptake value (SUVmax) in positron emission tomography were associated with survival after surgical resection. CONCLUSIONS Despite the possibility of major complications, DP-CAR could be a feasible option for achieving curative resection with fair survival outcomes in patients with borderline resectable or locally advanced pancreatic cancer. Further studies investigating the safety of the procedure and identifying proper surgical candidates with potential survival gains are necessary.
Collapse
Affiliation(s)
- So Jeong Yoon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.J.Y.); (J.S.H.)
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Ilsan 10408, Republic of Korea;
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang 13620, Republic of Korea;
| | - Tae-Ho Hong
- Department of HBP Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University, Seoul 06591, Republic of Korea;
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Republic of Korea;
| | - Hee Joon Kim
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Chonnam National University Hospital, Gwangju 61469, Republic of Korea;
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.J.Y.); (J.S.H.)
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (S.J.Y.); (J.S.H.)
| |
Collapse
|
7
|
Eshmuminov D, Aminjonov B, Palm RF, Malleo G, Schmocker RK, Abdallah R, Yoo C, Shaib WL, Schneider MA, Rangelova E, Choi YJ, Kim H, Rose JB, Patel S, Wilson GC, Maloney S, Timmermann L, Sahora K, Rössler F, Lopez-Lopez V, Boyer E, Maggino L, Malinka T, Park JY, Katz MHG, Prakash L, Ahmad SA, Helton S, Jang JY, Hoffe SE, Salvia R, Taieb J, He J, Clavien PA, Held U, Lehmann K. FOLFIRINOX or Gemcitabine-based Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Cancer: A Multi-institutional, Patient-Level, Meta-analysis and Systematic Review. Ann Surg Oncol 2023; 30:4417-4428. [PMID: 37020094 PMCID: PMC10250524 DOI: 10.1245/s10434-023-13353-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/01/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Pancreatic cancer often presents as locally advanced (LAPC) or borderline resectable (BRPC). Neoadjuvant systemic therapy is recommended as initial treatment. It is currently unclear what chemotherapy should be preferred for patients with BRPC or LAPC. METHODS We performed a systematic review and multi-institutional meta-analysis of patient-level data regarding the use of initial systemic therapy for BRPC and LAPC. Outcomes were reported separately for tumor entity and by chemotherapy regimen including FOLFIRINOX (FIO) or gemcitabine-based. RESULTS A total of 23 studies comprising 2930 patients were analyzed for overall survival (OS) calculated from the beginning of systemic treatment. OS for patients with BRPC was 22.0 months with FIO, 16.9 months with gemcitabine/nab-paclitaxel (Gem/nab), 21.6 months with gemcitabine/cisplatin or oxaliplatin or docetaxel or capecitabine (GemX), and 10 months with gemcitabine monotherapy (Gem-mono) (p < 0.0001). In patients with LAPC, OS also was higher with FIO (17.1 months) compared with Gem/nab (12.5 months), GemX (12.3 months), and Gem-mono (9.4 months; p < 0.0001). This difference was driven by the patients who did not undergo surgery, where FIO was superior to other regimens. The resection rates for patients with BRPC were 0.55 for gemcitabine-based chemotherapy and 0.53 with FIO. In patients with LAPC, resection rates were 0.19 with Gemcitabine and 0.28 with FIO. In resected patients, OS for patients with BRPC was 32.9 months with FIO and not different compared to Gem/nab, (28.6 months, p = 0.285), GemX (38.8 months, p = 0.1), or Gem-mono (23.1 months, p = 0.083). A similar trend was observed in resected patients converted from LAPC. CONCLUSIONS In patients with BRPC or LAPC, primary treatment with FOLFIRINOX compared with Gemcitabine-based chemotherapy appears to provide a survival benefit for patients that are ultimately unresectable. For patients that undergo surgical resection, outcomes are similar between GEM+ and FOLFIRINOX when delivered in the neoadjuvant setting.
Collapse
Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Botirjon Aminjonov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Ryan K Schmocker
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Raëf Abdallah
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel André Schneider
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Elena Rangelova
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology (CLINTEC) at Karolinska Institute, Stockholm, Sweden
- Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - J Bart Rose
- Division of Surgical Oncology, Pancreatobiliary Disease Center at UAB, The University of Alabama at Birmingham, Birmingham, USA
| | - Sameer Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah Maloney
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lea Timmermann
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Klaus Sahora
- Departments of Surgery and Comprehensive Cancer Center, University of Vienna, Medical University of Vienna, Vienna, Austria
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Laura Maggino
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Thomas Malinka
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Laura Prakash
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Julien Taieb
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Jin He
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
| |
Collapse
|
8
|
Kinny-Köster B, Habib JR, van Oosten F, Javed AA, Cameron JL, Burkhart RA, Burns WR, He J, Wolfgang CL. Conduits in Vascular Pancreatic Surgery: Analysis of Clinical Outcomes, Operative Techniques, and Graft Performance. Ann Surg 2023; 278:e94-e104. [PMID: 35838419 DOI: 10.1097/sla.0000000000005575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions. BACKGROUND Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce. METHODS We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency. RESULTS For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively. CONCLUSIONS Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.
Collapse
Affiliation(s)
- Benedict Kinny-Köster
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
| | - Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Floortje van Oosten
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
| |
Collapse
|
9
|
Miao Y, Cai B, Lu Z. Technical options in surgery for artery-involving pancreatic cancer: Invasion depth matters. Surg Open Sci 2023; 12:55-61. [PMID: 36936450 PMCID: PMC10020102 DOI: 10.1016/j.sopen.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/18/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Background The artery involvement explains the majority of primary unresectability of non-metastatic pancreatic cancer patients and both arterial resection and artery-sparing dissection techniques are utilized in curative-intent pancreatectomies for artery-involving pancreatic cancer (ai-PC) patients. Methods This narrative review summarized the history of resectability evaluation for ai-PC and attempted to interpret its current pitfalls that led to the divergence of resectability prediction and surgical exploration, with a focus on the rationale and the surgical outcomes of the sub-adventitial divestment technique. Results The circumferential involvement of artery by tumor currently defined the resectability of ai-PC but insufficient to preclude laparotomy with curative intent. The reasons behind could be: 1. The radiographic involvement of tumor to arterial circumference was not necessarily resulted in histopathological artery wall invasion; 2. the developed surgical techniques facilitated radical resection, better perioperative safety as well as oncological benefit. The feasibility of periadventitial dissection, sub-adventitial divestment and other artery-sparing techniques for ai-PC depended on the tumor invasion depth to the artery, i.e., whether the external elastic lamina (EEL) was invaded demonstrating a hallmark plane for sub-adventitial dissections. These techniques were reported to be complicated with preferable surgical outcomes comparing to arterial resection combined pancreatectomies, while the arterial resection combined pancreatectomies were considered performed in patients with more advanced disease. Conclusions Adequate preoperative imaging modalities with which to evaluate the tumor invasion depth to the artery are to be developed. Survival benefits after these techniques remain to be proven, with more and higher-level clinical evidence needed. Key message The current resectability evaluation criteria, which were based on radiographic circumferential involvement of the artery by tumor, was insufficient to preclude curative-intent pancreatectomies for artery-involving pancreatic cancer patients. With oncological benefit to be further proven, periarterial dissection and arterial resection have different but overlapping indications, and predicting the tumor invasion depth in major arteries was critical for surgical planning.
Collapse
Affiliation(s)
- Yi Miao
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, PR China
- Corresponding author at: Pancreas Center, The First Affiliated Hospital Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, PR China.
| | - Baobao Cai
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
| | - Zipeng Lu
- Pancreas Center, First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
| |
Collapse
|
10
|
Addeo P, Averous G, de Mathelin P, Faitot F, Cusumano C, Paul C, Dufour P, Bachellier P. Pancreatectomy After Neoadjuvant FOLFIRINOX Chemotherapy: Identifying Factors Predicting Long-Term Survival. World J Surg 2023; 47:1253-1262. [PMID: 36670291 DOI: 10.1007/s00268-023-06910-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION We aimed to evaluate the long-term outcomes of the association of neoadjuvant chemotherapy with pancreatectomy with vascular resection in patients with locally advanced pancreatic cancer. METHODS Clinical data from patients who underwent pancreatic resection after neoadjuvant FOLFIRINOX were retrospectively reviewed. Cox analyses were used to identify factors prognostic of overall survival (OS). RESULTS FOLFIRINOX protocol was administered pre-operatively with a median number of nine cycles (range 2-18) in 98 patients. Types of resections included pancreaticoduodenectomy (n = 53), total pancreatectomy (n = 17), and distal spleno-pancreatectomy (n = 28). Venous resection and arterial resections were performed in 85 (86.7%) and 64 patients (65.3%), respectively. The overall 90-day mortality and morbidity rates were 6.1% (n = 6) and 47% (n = 47), respectively. The median OS was 31.08 months after surgery. OS rates at one, three, five, and 10 years were 82%, 47%, 28%, and 21%, respectively. According to the type of vascular resection, median OS and 5-year survival rates were exclusive venous resection (31.08 months; 23%) and arterial resections (24.7 months; 27%). Multivariate Cox analysis found lymph node involvement, venous invasion, and total pancreatectomy as independent prognostic factors for OS. According to the presence of 0 or 1-3 risk factors, 5-year survival (85% vs 16%) and median overall survival rates (not reached versus 24.7 months, respectively) were statistically significantly different (p < 0.0001). CONCLUSIONS A multimodal treatment, including neoadjuvant FOLFIRINOX combined with pancreatectomy with venous and arterial resection, achieves long term survival rates in patients with locally advanced disease. Surgery, in experienced centers, should be integrated into the treatment of patients with locally advanced pancreatic adenocarcinomas.
Collapse
Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France.
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pierre de Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France
| | - François Faitot
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France
| | - Caterina Cusumano
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France
| | - Chloe Paul
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France
| | - Patrick Dufour
- Department of Oncology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques Et de La Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France 1, Avenue Moliere, 67098, Strasbourg, France
| |
Collapse
|
11
|
Li X, Liu X, Lu N, Chen Y, Zhang X, Guo C, Xiao W, Xue X, Sun K, Wang M, Gao S, Shen Y, Zhang M, Wu J, Que R, Yu J, Bai X, Liang T. Normalization of tumor markers and a clear resection margin affect progression-free survival of patients with unresectable pancreatic cancer who have undergone conversion surgery. BMC Cancer 2023; 23:49. [PMID: 36641427 PMCID: PMC9840266 DOI: 10.1186/s12885-023-10529-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND With the advent of intensive combination regimens, an increasing number of patients with unresectable pancreatic cancer (UPC) have regained the opportunity for surgery. We investigated the clinical benefits and prognostic factors of conversion surgery (CS) in UPC patients. METHODS We retrospectively enrolled patients with UPC who had received CS following first-line systemic treatment in our center between 2014 to 2022. Treatment response, safety of the surgical procedure and clinicopathological data were collected. We analyzed the prognostic factors for postoperative survival among UPC patients who had CS. RESULTS Sixty-seven patients with UPC were enrolled (53 with locally advanced pancreatic cancer (LAPC) and 14 with metastatic pancreatic cancer (MPC)). The duration of preoperative systemic treatment was 4.17 months for LAPC patients and 6.52 months for MPC patients. All patients experienced a partial response (PR) or had stable disease (SD) preoperatively according to imaging. Tumor resection was unsuccessful in four patients and, finally, R0 resection was obtained in 81% of cases. Downstaging was determined pathologically in 87% of cases; four patients achieved a complete pathological response. Median postoperative-progression-free survival (PO-PFS) was 9.77 months and postoperative overall survival (PO-OS) was 31.2 months. Multivariate logistic regression analyses revealed that the resection margin and postoperative changes in levels of tumor markers were significant prognostic factors for PO-PFS. No factors were associated significantly with PO-OS according to multivariate analyses. CONCLUSIONS CS is a promising strategy for improving the prognosis of UPC patients. The resection margin and postoperative change in levels of tumor markers are the most important prognostic factors for prolonged PFS. Multidisciplinary treatment in high-volume centers is strongly recommended. Prospective studies must be undertaken to resolve the various problems regarding optimal regimens, the duration of treatment, and detailed criteria for CS.
Collapse
Affiliation(s)
- Xiang Li
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Xinyuan Liu
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Na Lu
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Yiwen Chen
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Xiaochen Zhang
- grid.452661.20000 0004 1803 6319Department of Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengxiang Guo
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Wenbo Xiao
- grid.452661.20000 0004 1803 6319Department of Radiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xing Xue
- grid.452661.20000 0004 1803 6319Department of Radiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ke Sun
- grid.452661.20000 0004 1803 6319Department of Pathology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Meng Wang
- grid.452661.20000 0004 1803 6319Department of Pathology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Yan Shen
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Min Zhang
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Jian Wu
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Risheng Que
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Jun Yu
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Xueli Bai
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Tingbo Liang
- grid.452661.20000 0004 1803 6319Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China ,grid.452661.20000 0004 1803 6319Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China ,grid.13402.340000 0004 1759 700XZhejiang University Cancer Center, Hangzhou, China
| |
Collapse
|
12
|
Shin D, Hong S, Park Y, Kwak BJ, Lee W, Song KB, Lee JH, Kim SC, Hwang DW. Outcomes of Distal Pancreatectomy With Celiac Axis Resection for Pancreatic Cancer. Pancreas 2023; 52:e54-e61. [PMID: 37378900 DOI: 10.1097/mpa.0000000000002218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES This study aimed to show the clinical and oncologic outcomes of distal pancreatectomy with celiac axis resection (DP-CAR) from a high-volume single center and analyze them from diverse perspectives. METHODS Forty-eight patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR were included in the study. The primary outcome was morbidity and 90-day mortality, and the secondary outcome was overall survival and disease-free survival. RESULTS Morbidity (Clavien-Dindo classification grade ≥3) occurred in 12 patients (25.0%). Thirteen patients (27.1%) had pancreatic fistula grade B and 3 patients (6.3%) had delayed gastric emptying. The 90-day mortality was 2.1% (n = 1). The median overall survival was 25.5 months (interquartile range, 12.3-37.5 months) and median disease-free survival was 7.5 months (interquartile range, 4.0-17.0 months). During the follow-up period, 29.2% of participants survived for up to 3 years and 6.3% survived for up to 5 years. CONCLUSIONS Despite its associated morbidity and mortality, DP-CAR should be considered as the only therapeutic option for pancreatic body and tail cancer with celiac axis involvement when carried out on carefully selected patients performed by a highly experienced group.
Collapse
Affiliation(s)
- Dakyum Shin
- From the Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Cai B, Bergmann F, Lu Z, Neoptolemos JP, Li M, Yin L, Gao Y, Xu C, Jiang K, Büchler MW, Miao Y. A histopathological study of artery wall involvement in pancreatic cancer surgery. Langenbecks Arch Surg 2022. [DOI: 10.1007/s00423-022-02689-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022]
|
14
|
Stoop TF, Mackay TM, Brada LJH, van der Harst E, Daams F, Land FRV‘, Kazemier G, Patijn GA, van Santvoort HC, de Hingh IH, Bosscha K, Seelen LWF, Nijkamp MW, Stommel MWJ, Liem MSL, Busch OR, Coene PPLO, van Dam RM, de Wilde RF, Mieog JSD, Quintus Molenaar I, Besselink MG, van Eijck CHJ, de Meijer VE, Olij B, den Dulk M, Ramaekers M, Bonsing BA, Michiels N, Koerkamp BG, Festen S, Wit F, Lips DJ, Draaisma W, Manusama E, te Riele W. Pancreatectomy with arterial resection for periampullary cancer: outcomes after planned or unplanned events in a nationwide, multicentre cohort. Br J Surg 2022; 110:638-642. [PMID: 36308339 PMCID: PMC10364546 DOI: 10.1093/bjs/znac353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/09/2022] [Accepted: 09/30/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Tara M Mackay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Lilly J H Brada
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | | | - Freek Daams
- Cancer Center Amsterdam , Amsterdam , The Netherlands
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery , Amsterdam , The Netherlands
| | - Freek R van ‘t Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam , Amsterdam , The Netherlands
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery , Amsterdam , The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics , Zwolle , The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital , Eindhoven , The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital , ‘s Hertogenbosch , The Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Groningen , Groningen , The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente , Enschede , The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | | | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen , Aachen , Germany
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center , Leiden , The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Kiguchi G, Sugioka A, Uchida Y, Mii S, Kojima M, Takahara T, Kato Y, Suda K, Uyama I. Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using retroperitoneal-first laparoscopic approach (Retlap): A novel minimally invasive approach for determining resectability and achieving tumor-free resection margins of locally advanced pancreatic body cancer. Surg Oncol 2022; 45:101857. [PMID: 36252411 DOI: 10.1016/j.suronc.2022.101857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/04/2022] [Accepted: 09/26/2022] [Indexed: 10/14/2022]
|
16
|
Tsiotos GG, Ballian N, Milas F, Peraki E, Kostopanagiotou G, Tsigaridas K. Aorta to proper hepatic artery bypass with total pancreatectomy and celiac axis resection (TP-CAR) in a patient with locally advanced pancreas adenocarcinoma. Int J Surg Case Rep 2022; 98:107544. [PMID: 36055170 PMCID: PMC9482927 DOI: 10.1016/j.ijscr.2022.107544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Total pancreatectomy with en-bloc celiac axis resection (TP-CAR) and interposition graft placement between the aorta and the proper hepatic artery is a technically demanding, very uncommonly performed operation, even in high-volume pancreatic centers. Presentation of case We present, in clinical and technical detail, a patient with locally advanced adenocarcinoma of the pancreatic body and neck involving the celiac and common hepatic arteries and portal vein, who underwent neoadjuvant chemotherapy and radiation with very good response, followed by TP-CAR and aorto-proper hepatic artery bypass using saphenous vein graft. The patient had an uneventful intraoperative and postoperative course, short hospital stay, and histology consistent with a curative resection. Discussion TP-CAR with common hepatic artery resection and proper hepatic artery reconstruction in patients with locally advanced pancreatic body cancer after appropriate neoadjuvant therapy can be performed safely and be potentially curative in centers with an established track record in advanced pancreatic surgery involving major peripancreatic vessels. Conclusion TP-CAR with proper hepatic artery reconstruction is a rare but potentially curative operation for selected patients with otherwise unresectable pancreatic adenocarcinoma. TP-CAR and aorto-PHA bypass graft: A very rare, technically demanding operation with significant morbidity & mortality This operation may provide curative (R0) resection of an otherwise unresectable cancer Our patient had optimal perioperative outcome and excellent histology result To the best of our knowledge this is the first TP-CAR with aorto-PHA bypass graft case in Greece
Collapse
Affiliation(s)
| | | | - Fotios Milas
- Departments of Surgery, Mitera-Hygeia Hospitals, Athens, Greece
| | | | | | | |
Collapse
|
17
|
Seppälä TT, Zimmerman JW, Suri R, Zlomke H, Ivey GD, Szabolcs A, Shubert CR, Cameron JL, Burns WR, Lafaro KJ, He J, Wolfgang CL, Zou YS, Zheng L, Tuveson DA, Eshleman JR, Ryan DP, Kimmelman AC, Hong TS, Ting DT, Jaffee EM, Burkhart RA. Precision Medicine in Pancreatic Cancer: Patient-Derived Organoid Pharmacotyping Is a Predictive Biomarker of Clinical Treatment Response. Clin Cancer Res 2022; 28:3296-3307. [PMID: 35363262 PMCID: PMC9357072 DOI: 10.1158/1078-0432.ccr-21-4165] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Patient-derived organoids (PDO) are a promising technology to support precision medicine initiatives for patients with pancreatic ductal adenocarcinoma (PDAC). PDOs may improve clinical next-generation sequencing (NGS) and enable rapid ex vivo chemotherapeutic screening (pharmacotyping). EXPERIMENTAL DESIGN PDOs were derived from tissues obtained during surgical resection and endoscopic biopsies and studied with NGS and pharmacotyping. PDO-specific pharmacotype is assessed prospectively as a predictive biomarker of clinical therapeutic response by leveraging data from a randomized controlled clinical trial. RESULTS Clinical sequencing pipelines often fail to detect PDAC-associated somatic mutations in surgical specimens that demonstrate a good pathologic response to previously administered chemotherapy. Sequencing the PDOs derived from these surgical specimens, after biomass expansion, improves the detection of somatic mutations and enables quantification of copy number variants. The detection of clinically relevant mutations and structural variants is improved following PDO biomass expansion. On clinical trial, PDOs were derived from biopsies of treatment-naïve patients prior to treatment with FOLFIRINOX (FFX). Ex vivo PDO pharmacotyping with FFX components predicted clinical therapeutic response in these patients with borderline resectable or locally advanced PDAC treated in a neoadjuvant or induction paradigm. PDO pharmacotypes suggesting sensitivity to FFX components were associated with longitudinal declines of tumor marker, carbohydrate-antigen 19-9 (CA-19-9), and favorable RECIST imaging response. CONCLUSIONS PDOs established from tissues obtained from patients previously receiving cytotoxic chemotherapies can be accomplished in a clinically certified laboratory. Sequencing PDOs following biomass expansion improves clinical sequencing quality. High in vitro sensitivity to standard-of-care chemotherapeutics predicts good clinical response to systemic chemotherapy in PDAC. See related commentary by Zhang et al., p. 3176.
Collapse
Affiliation(s)
- Toni T. Seppälä
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Abdominal Surgery, Helsinki University Hospital, Helsinki, Finland
- Applied Tumor Genomics Research Program, University of Helsinki, Helsinki, Finland
| | - Jacquelyn W. Zimmerman
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Reecha Suri
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haley Zlomke
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gabriel D. Ivey
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Annamaria Szabolcs
- The Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Christopher R Shubert
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - John L. Cameron
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - William R. Burns
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Kelly J Lafaro
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Jin He
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | | | - Ying S. Zou
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - David A. Tuveson
- Lustgarten Foundation Pancreatic Cancer Research Laboratory, Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| | - James R. Eshleman
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David P. Ryan
- The Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alec C. Kimmelman
- Department of Radiation Oncology at New York University Grossman School of Medicine, New York, NY, USA
| | - Theodore S. Hong
- The Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - David T. Ting
- The Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Elizabeth M. Jaffee
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | - Richard A. Burkhart
- Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Cancer Convergence Institute, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
- Lustgarten Foundation Pancreatic Cancer Research Laboratory, Cold Spring Harbor Laboratory, Cold Spring Harbor, NY, USA
| |
Collapse
|
18
|
Konishi T, Takamoto T, Fujiogi M, Hashimoto Y, Matsui H, Fushimi K, Tanabe M, Seto Y, Yasunaga H. Laparoscopic versus open distal pancreatectomy with or without splenectomy: A propensity score analysis in Japan. Int J Surg 2022; 104:106765. [PMID: 35811012 DOI: 10.1016/j.ijsu.2022.106765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/21/2022] [Accepted: 07/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the laparoscopic approach has been applied to distal pancreatectomy, its benefits with regard to the short-term outcomes of distal pancreatectomy remain unclear. MATERIALS AND METHODS Using a Japanese nationwide inpatient database, we identified patients who underwent laparoscopic (n = 6647) and open (n = 21,843) distal pancreatectomy between July 2012 and March 2020. We conducted a 1:2 propensity score-matched analysis with adjustment for background characteristics (e.g., comorbidities, preoperative diagnosis, and hospital background) to compare in-hospital morbidity and mortality, reoperation requirement, duration of anesthesia and drainage, postoperative length of stay, and total hospitalization costs. For sensitivity analyses, we performed overlap propensity score-weighted analysis, instrumental variable analysis, and subgroup analyses for hospital volume, patients with benign tumors, and those with malignant tumors that required splenectomy. RESULTS In-hospital morbidity and mortality were 27% and 0.7%, respectively. The 1:2 propensity score-matched analysis showed that compared to open surgery, laparoscopic surgery was significantly associated with lower in-hospital morbidity (odds ratio [95% confidence interval]: 0.78 [0.73 to 0.84]) and mortality (0.26 [0.14 to 0.50]), lower occurrence of postoperative pancreatic fistula (0.78 [0.72 to 0.85]), postoperative bleeding (0.59 [0.51 to 0.69]), and reoperation (0.65 [0.58 to 0.75]), longer duration of anesthesia (difference, 59 [56 to 63] minutes), shorter duration of drainage (difference, -4.0 [-4.5 to -3.6] days) and postoperative length of stay (difference, -4.4 [-4.9 to -3.9] days), and lower total hospitalization costs (difference, -1510 [-1776 to -1243] US dollars). The sensitivity analyses showed compatible results with those from the main analysis. CONCLUSION In this large nationwide cohort, laparoscopic distal pancreatectomy showed lower in-hospital morbidity, mortality, and total hospitalization costs than open distal pancreatectomy. Laparoscopic distal pancreatectomy may be a favorable procedure in terms of both complications and costs.
Collapse
Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan.
| | - Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Japan
| | - Michimasa Fujiogi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Japan
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| |
Collapse
|
19
|
Egorov V, Kim P, Kharazov A, Dzigasov S, Popov P, Rykova S, Zelter P, Demidova A, Kondratiev E, Grigorievsky M, Sorokin A. Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization. Cancers (Basel) 2022; 14. [PMID: 35267562 DOI: 10.3390/cancers14051254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
DPCAR’s short- and long-term outcomes are highly diverse, while the causes and prevention of ischemic complications are unclear. To assess oncological, surgical, and hemodynamic outcomes of 40 consecutive DPCARs for pancreatic (n37) and gastric tumors (n3) (2009−2021), retrospective analyses of mortality, morbidity, survival, and hemodynamic consequences after DPCAR were undertaken using case history data, IOUS, and pre- and postoperative CT measurements. In postoperative complications (42.5%), the pancreatic fistula was the most frequent event (27%), 90-day mortality was 7.5. With 27 months median follow-up, median overall (OS) and progression-free survival (PFS) for PDAC were 29 and 18 months, respectively; with 1-, 3-, and 5-years, the OS were 90, 60, and 28%, with an R0-resection rate of 92.5%. Liver and gastric ischemia developed in 0 and 5 (12.5%) cases. Comparison of clinical and vascular geometry data revealed fast adaptation of collateral circulation, insignificant changes in proper hepatic artery diameter, and high risk of ischemic gastropathy if the preoperative diameter of pancreaticoduodenal artery was <2 mm. DP CAR can be performed with acceptable morbidity and survival. OS and RFS in this super-selective cohort were compared to those for resectable cancer. The changes in the postoperative arterial geometry could explain the causes of ischemic complications and determine directions for their prevention.
Collapse
|
20
|
Gemenetzis G, Blair AB, Nagai M, Groot VP, Ding D, Javed AA, Burkhart RA, Fishman EK, Hruban RH, Weiss MJ, Cameron JL, Narang A, Laheru D, Lafaro K, Herman JM, Zheng L, Burns WR, Wolfgang CL, He J. Anatomic Criteria Determine Resectability in Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2022; 29:401-414. [PMID: 34448965 PMCID: PMC8688211 DOI: 10.1245/s10434-021-10663-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/01/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. RESULTS Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p < 0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). CONCLUSIONS Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.
Collapse
Affiliation(s)
- Georgios Gemenetzis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Royal Infirmary Edinburgh, Edinburgh, Scotland, UK
| | - Alex B Blair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Minako Nagai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Vincent P Groot
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
21
|
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: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
22
|
Muzzolini M, Araujo RLC, Kingham TP, Peschaud F, Paye F, Lupinacci RM. Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review. Eur J Surg Oncol 2021; 48:707-717. [PMID: 34887165 DOI: 10.1016/j.ejso.2021.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy. METHODS A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality. RESULTS Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases. CONCLUSIONS The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.
Collapse
Affiliation(s)
- Milena Muzzolini
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France
| | - Raphael L C Araujo
- Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frédérique Peschaud
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France
| | - François Paye
- Department of Surgery, Saint Antoine Hospital, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France; Sorbonne Université, 75013, 91-105, Bd de l'Hôpital, Paris, France
| | - Renato M Lupinacci
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France.
| |
Collapse
|
23
|
Wu YHA, Oba A, Lin R, Watanabe S, Meguid C, Schulick RD, Del Chiaro M. Selecting surgical candidates with locally advanced pancreatic cancer: a review for modern pancreatology. J Gastrointest Oncol 2021; 12:2475-2483. [PMID: 34790408 DOI: 10.21037/jgo-21-119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 05/14/2021] [Indexed: 12/27/2022] Open
Abstract
Pancreatic cancer (PC) is likely to become the second leading cause of malignancy-associated mortality within the next 10 years and surgery remains the best hope for cure. The introduction of effective neoadjuvant treatment (NAT) has increased the resection rate of PC in the era of contemporary pancreatology. This review summarizes the surgical selection criteria for locally advanced PC (LAPC), by focusing on the commonly used predictors for resectability and better overall survival outcome. Based on the currently available evidence, the role of change in carbohydrate antigen 19-9 (CA 19-9) and patient's tumor response to NAT are critical in surgical candidacy selection. Although, consensus on surgical candidacy selection for LAPC still needs to be made, several data have shown that surgery provides the most optimistic chance of cure for PC. Surgery is, therefore, recommended whenever the benefits of pancreatectomy outweigh surgical complications, and the chance of local or distant metastases in the postoperative setting is low. This review also provided our insight for and experience in selecting surgical candidates by focusing on optimizing the overall survival of LAPC patients. Nevertheless, a collaborative approach to formulating standardized criteria for surgical candidate selection and treatment guidelines for LAPC is a common goal that pancreatologists worldwide should focus on.
Collapse
Affiliation(s)
- Y H Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ronggui Lin
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shuichi Watanabe
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Cancer Center, Aurora, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,University of Colorado Cancer Center, Aurora, CO, USA
| |
Collapse
|
24
|
Varghese C, Wells CI, Lee S, Pathak S, Siriwardena AK, Pandanaboyana S. Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery. Surgery 2021; 171:490-497. [PMID: 34417025 DOI: 10.1016/j.surg.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown. METHODS MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak. RESULTS Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies. CONCLUSION The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.
Collapse
Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/chrisvarghese98
| | - Cameron Iain Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/drcamwells
| | - Shiela Lee
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Samir Pathak
- Department of Oncology and Surgery, St James Hospital, Leeds, UK. https://twitter.com/Drsampathak
| | - Ajith K Siriwardena
- Department of Hepatobiliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
| |
Collapse
|
25
|
Nigri G, Petrucciani N, Belloni E, Lucarini A, Aurello P, D'Angelo F, di Saverio S, Fancellu A, Ramacciato G. Distal Pancreatectomy with Celiac Axis Resection: Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:1967. [PMID: 33921838 DOI: 10.3390/cancers13081967] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 02/05/2023] Open
Abstract
Simple Summary The literature is conflicting regarding the feasibility and survival outcomes of distal pancreatectomy with celiac axis resection (DP-CAR), although this procedure, in selected cases, represents the only therapeutical option for patients with locally advanced pancreatic cancer. The available studies often include small surgical populations, and there are important variations in the inclusion criteria and pre- and post-operative treatment. The purpose of this study was to provide an overview of the literature of the last 15 years, to evaluate the efficacy and the clinical safety of this procedure. This could help physicians in the choice of a multidisciplinary targeted therapeutical plan for patients. The combination of neoadjuvant chemo/radiochemotherapy and demolitive surgeries such as DP-CAR could have a role in changing the survival outcomes of patients with locally advanced pancreatic adenocarcinoma. Abstract Background: Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive surgeries such as distal pancreatectomy with celiac axis resection (DP-CAR) have become a therapeutical option. Methods: A meta-analysis of studies comparing DP-CAR and standard DP in patients with pancreatic adenocarcinoma was conducted. Moreover, a systematic review of studies analyzing oncological, postoperative and survival outcomes of DP-CAR was conducted. Results: Twenty-four articles were selected for the systematic review, whereas eleven were selected for the meta-analysis, for a total of 1077 patients. Survival outcomes between the two groups were similar in terms of 1 year overall survival (OS) (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.34 to 1.31, p = 0.24). Patients who received DP-CAR were more likely to have T4 tumors (OR 28.45, 95% CI 10.46 to 77.37, p < 0.00001) and positive margins (R+) (OR 2.28, 95% CI 1.24 to 4.17, p = 0.008). Overall complications (OR, 1.72, 95% CI, 1.15 to 2.58, p = 0.008) were more frequent in the DP-CAR group, whereas rates of pancreatic fistula (OR 1.16, 95% CI 0.81 to 1.65, p = 0.41) were similar. Conclusions: DP-CAR was not associated with higher mortality compared to standard DP; however, overall morbidity was higher. Celiac axis involvement should no longer be considered a strict contraindication to surgery in patients with locally advanced pancreatic adenocarcinoma. Considering the different baseline tumor characteristics, DP-CAR may need to be compared with palliative therapies instead of standard DP.
Collapse
|
26
|
Rosumeck N, Timmermann L, Klein F, Bahra M, Stintzig S, Malinka T, Pelzer U. Induction Chemotherapy for Primarily Unresectable Locally Advanced Pancreatic Adenocarcinoma-Who Will Benefit from a Secondary Resection? ACTA ACUST UNITED AC 2021; 57:77. [PMID: 33477505 DOI: 10.3390/medicina57010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/31/2020] [Accepted: 01/15/2021] [Indexed: 11/18/2022]
Abstract
Background and Objectives: An increasing number of patients (pts) with locally advanced pancreatic cancer (LAPC) are treated with an intensive neoadjuvant therapy to obtain a secondary curative resection. Only a certain number of patients benefit from this intention. The aim of this investigation was to identify prognostic factors which may predict a benefit for secondary resection. Materials and Methods: Survival time and clinicopathological data of pts with pancreatic cancer were prospective and consecutively collected in our Comprehensive Cancer Center Database. For this investigation, we screened for pts with primarily unresectable pancreatic cancer who underwent a secondary resection after receiving induction therapy in the time between March 2017 and May 2019. Results: 40 pts had a sufficient database to carry out a reliable analysis. The carbohydrate-antigen 19-9 (CA 19-9) level of the pts treated with induction therapy decreased by 44.7% from 4358.3 U/mL to 138.5 U/mL (p = 0.001). The local cancer extension was significantly reduced (p < 0.001), and the Eastern Cooperative Oncology Group (ECOG) performance status was lowered (p = 0.03). The median overall survival (mOS) was 20 months (95% CI: 17.2–22.9). Pts who showed a normal CA 19-9 level (<37 U/mL) at diagnosis and after neoadjuvant therapy or had a Body Mass Index (BMI) below 25 kg/m2 after chemotherapy had a significant prolonged overall survival (29 vs. 19 months, p = 0.02; 26 vs. 18 months, p = 0.04; 15 vs. 24 months, p = 0.01). Pts who still presented elevated CA 19-9 levels >400 U/mL after induction therapy did not profit from a secondary resection (24 vs. 7 months, p < 0.001). Nodal negativity as well as the performance of an adjuvant therapy lead to better mOS (25 vs. 15 months, p = 0.003; 10 vs. 25 months, p < 0.001). Conclusion: The pts in our investigation had different benefits from the multimodal treatment. We identified the CA 19-9 level at time of diagnosis and after neoadjuvant therapy as well as the preoperative BMI as predictive factors for overall survival. Furthermore, diagnostics of presurgical nodal status should gain more importance as nodal negativity is associated with better outcome.
Collapse
|