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Tchouta LN, Schrope BA. Evolving Technique for Puestow-Type Procedure for Chronic Pancreatitis: The Combined Roux-en-Y Proximal End-to-Side and Distal Longitudinal Pancreatojejunostomy. Am J Case Rep 2024; 25:e942066. [PMID: 38243588 PMCID: PMC10812291 DOI: 10.12659/ajcr.942066] [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: 08/06/2023] [Revised: 12/19/2023] [Accepted: 11/21/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND The goal of surgical procedures in chronic pancreatitis is to establish drainage of the duct throughout the gland as well as resect any inflammatory masses if present. Conventionally, for patients with a dilated pancreatic duct without inflammatory masses, a drainage procedure in the form of a longitudinal pancreatojejunostomy (or Partington-Rochelle modification of the Puestow procedure) is the procedure of choice. CASE REPORT In present case, a patient with chronic pancreatitis was evaluated for surgical management, but extensive intraductal and parenchymal pancreaticolithiasis throughout the entire gland considerably restricted access to the duct. A novel combined Roux-en-Y partial longitudinal pancreatojejunostomy of the body and tail with an end-to-side pancreatojejunostomy of the head was fashioned to facilitate drainage of the entire pancreas, without resection of any parenchyma. The patient's immediate postoperative course was uncomplicated, and at her 30-day follow-up, she had been without pain and had been tolerating a diet, with additional pancreatic enzyme supplementation. CONCLUSIONS Roux-en-Y partial longitudinal pancreatojejunostomy (or modified Puestow procedure) should be considered a viable option for the surgical management of chronic pancreatitis with extensive pancreaticolithiasis, with good short-term outcomes. It underscores the importance of leveraging anatomic limitations to expand the choice of drainage procedure for chronic pancreatitis. This procedure should be considered in those patients with significant pancreaticolithiasis, where clear visualization of the main pancreatic duct is limited, precluding a lengthy pancreatojejunostomy.
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Affiliation(s)
- Lise N. Tchouta
- Department of Surgery, Columbia University Medical Center, New York City, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York City, NY, USA
| | - Beth A. Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York City, NY, USA
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Koerner AS, Thomas AS, Chabot JA, Kluger MD, Sugahara KN, Schrope BA. Associations Between Patient Characteristics and Whipple Procedure Outcomes Before and After Implementation of an Enhanced Recovery After Surgery Protocol. J Gastrointest Surg 2023; 27:1855-1866. [PMID: 37165160 DOI: 10.1007/s11605-023-05693-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/22/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal perioperative care bundle aimed to improve pancreatic surgery outcomes. This work evaluates whether a Whipple ERAS protocol can be safely implemented at a quaternary care center. We also aimed to assess if race and socioeconomic factors are associated with disparities in outcomes in patients undergoing a Whipple ERAS protocol. METHODS A retrospective review identified demographic and clinical data for 458 patients undergoing pancreaticoduodenectomies (PDs) at a single institution from October 2017 to May 2022. Patients were split into two cohorts: pre-ERAS (treated before implementation) and ERAS (treated after). Outcomes included length of stay (LOS), 30-day readmission and mortality rates, and major complications. RESULTS There were 213 pre-ERAS PD patients, and 245 were managed with an ERAS protocol. More ERAS patients had a BMI > 30 (15.5% vs. 8.0%; p = 0.01) and received neoadjuvant chemotherapy (15.5% vs. 4.2%; p < 0.001). ERAS patients had a higher rate of major complications (57.6% vs. 37.6%; p < 0.001). Medicaid patients did not have more complications or longer LOS compared to non-Medicaid patients. On univariate analysis, race/ethnicity or gender was not significantly associated with a higher rate of major complications or prolonged LOS. CONCLUSION A Whipple ERAS protocol did not significantly change LOS, readmissions, or 30-day mortality. Rate of overall complications did not significantly change after implementation, but rate of major complications increased. These outcomes were not significantly impacted by race/ethnicity, gender, tumor staging, or insurance status.
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Affiliation(s)
- Anna S Koerner
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
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Goel N, Rhim AD, Xi H, Olive KP, Thomas AS, Kwon W, Schwartz J, Sugahara KN, Schrope BA, Chabot JA, Kluger MD. Transfusion of salvaged red blood cells during pancreatic ductal adenocarcinoma operations. Br J Surg 2023; 110:917-919. [PMID: 36461883 PMCID: PMC10361671 DOI: 10.1093/bjs/znac393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/26/2022] [Accepted: 10/24/2022] [Indexed: 07/20/2023]
Affiliation(s)
- Neha Goel
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrew D Rhim
- Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, Houston, Texas, USA
| | - Huaqing Xi
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Kenneth P Olive
- Department of Medicine, Division of Digestive and Liver Diseases, and Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York, USA
| | - Alexander S Thomas
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Wooil Kwon
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Joseph Schwartz
- Department of Anatomic Pathology and Clinical Pathology, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kazuki N Sugahara
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Thomas AS, Kwon W, Horowitz DP, Bates SE, Fojo AT, Manji GA, Schreibman S, Schrope BA, Chabot JA, Kluger MD. Long-term follow-up experience with adjuvant therapy after irreversible electroporation of locally advanced pancreatic cancer. J Surg Oncol 2022; 126:1442-1450. [PMID: 36048146 DOI: 10.1002/jso.27085] [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: 05/10/2022] [Revised: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) expands the surgical options for patients with unresectable pancreatic cancer. This study evaluated for differences in survival stratified by type of IRE and receipt of adjuvant chemotherapy. METHODS Patients with locally advanced pancreatic cancer treated by IRE (2012-2020) were retrospectively included. Overall survival (OS) and recurrence-free survival (RFS) were compared by type of IRE (in situ for local tumor control or IRE of potentially positive margins with resection) and by receipt of adjuvant chemotherapy. RESULTS Thirty-nine patients had IRE in situ, 61 had IRE for margin extension, and 19 received adjuvant chemotherapy. Most (97.00%) underwent induction chemotherapy. OS was 28.71 months (interquartile range [IQR] 19.17, 51.19) from diagnosis, with no difference by IRE type (hazard ratio [HR] 1.05 for margin extension [p = 0.85]) or adjuvant chemotherapy (HR 1.14 [p = 0.639]). RFS was 8.51 months (IQR 4.95, 20.17) with no difference by IRE type (HR 0.90 for margin extension [p = 0.694]) or adjuvant chemotherapy (HR 0.90 [p = 0.711]). CONCLUSION These findings suggest that adjuvant therapy may have limited benefit for patients treated with induction chemotherapy followed by local control with IRE for unresectable pancreatic cancer. Further study of the duration and timing of systemic therapy is warranted to maximize benefit and limit toxicity.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Wooil Kwon
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA.,Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - David P Horowitz
- Department of Radiation Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical New York, New York, New York, USA
| | - Susan E Bates
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Antonio T Fojo
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Gulam A Manji
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Stephen Schreibman
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Thomas AS, Sharma RK, Kwon W, Sugahara KN, Chabot JA, Schrope BA, Kluger MD. Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State. J Gastrointest Surg 2022; 26:1647-1662. [PMID: 35501551 DOI: 10.1007/s11605-022-05320-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE We evaluated how race and socioeconomic factors impact access to high-volume surgical centers, treatment initiation, and postoperative care for pancreatic cancer in a state with robust safety net insurance coverage and healthcare infrastructure. METHODS The New York Statewide Planning and Research Cooperative System was analyzed. Patients with pancreatic cancer resected from 2007 to 2017 were identified by ICD and CPT codes. Primary outcomes included surgery at low-volume facilities (< 20 pancreatectomies/year), time to therapy initiation, and time to postoperative surveillance imaging (within 60-180 days after surgery). RESULTS In total, 3312 patients underwent pancreatectomy across 124 facilities. Median age was 67 years (IQR 59, 75) and 55% of patients were male. Most (72.7%) had surgery at high-volume centers. On multivariable analysis, odds ratios for surgery at low-volume centers were increased for Black race (2.21 (95% CI 1.69-2.88)), Asian race (1.64 (95% CI 1.09-2.43)), Hispanic ethnicity (1.68 (95% CI 1.24-2.28)), Medicaid insurance (2.52 (95% CI 1.79-3.56)), no insurance (2.24 (95% CI 1.38-3.61)), lowest income quartile (3.31 (95% CI 2.14-5.32)), and rural zip code (2.49 (95% CI 1.69-3.65)). Patients treated at low-volume centers waited longer to initiate treatment (hazard ratio (HR) 0.91 (95% CI 0.81-1.01)). Black patients underwent the least surveillance imaging (50.4%; p < 0.0001), while Asian (HR 2.04, 95% CI 1.40-2.98)) and Hispanic patients (HR 1.36 (95% CI 1.00-1.84)) were more likely to have surveillance imaging. CONCLUSIONS Race independently affected access to high-volume facilities and surveillance imaging. When considered in light of other accumulating evidence, future efforts might investigate the perceptions and logistical considerations noted by providers and patients alike to identify the etiology of these disparities and then institute corrective measures.
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Affiliation(s)
- Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA.
| | - Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
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Thomas AS, Huang Y, Kwon W, Schrope BA, Sugahara K, Chabot JA, Wright JD, Kluger MD. Prevalence and Risk Factors for Pancreatic Insufficiency After Partial Pancreatectomy. J Gastrointest Surg 2022; 26:1425-1435. [PMID: 35318597 DOI: 10.1007/s11605-022-05302-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aimed to determine the rate, timing, and predictors of diabetes and exocrine pancreatic insufficiency after pancreatectomy in order to inform preoperative patient counseling and risk management strategies. METHODS Using prescription claims as a surrogate for disease prevalence, IBM Watson Health MarketScan was queried for claims patterns pre- and post-pancreatectomy. Multivariable models explored associations between clinical characteristics and medication use within 2 years of surgery. RESULTS In total, 18.96% of 2,848 pancreaticoduodenectomy (PD) patients and 18.95% of 1,858 distal pancreatectomy (DP) patients had preoperative diabetic medication prescription claims. Fewer (6.6% and 3.88%, respectively) had pancreatic enzyme replacement therapy (PERT) claims. Diabetic medication claims increased to 28.69% after PD and 38.59% after DP [adjusted relative risk (aRR) = 1.36 (95% CI 1.27, 1.46)]. Other associated factors included age > 45, medical comorbidity, and obesity. The incidence of new diabetic medication claims among medication naïve patients was 13.78% for PD and 24.7% for DP (p < 0.001) with a median 4.7 and 4.9 months post-operatively. The prevalence of PERT claims was 55.97% after PD and 17.06% after DP [aRR = 0.32 (0.29, 0.36)]. The incidence of postoperative PERT claims 53.98% (PD) and 14.84% (DP) (p < 0.0001). The median time to new PERT claim was 3.0 (PD) and 3.2 (DP) months, respectively. Claims for both diabetic medications and PERT rose sharply after surgery and plateaued within 6 months. CONCLUSIONS This study defines prevalence, timing, and predictors for post-pancreatectomy insufficiency to inform preoperative counseling, risk modification strategies, and interventions related to quality of life.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA.
| | - Yongmei Huang
- Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Wooil Kwon
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - Kazuki Sugahara
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - John A Chabot
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
| | - Jason D Wright
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Michael D Kluger
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, 177 Fort Washington Ave 7GS, New York, NY, 10032, USA
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Kluger MD, Huang YY, Kuo JH, Kwon W, Thomas AS, Hershman DL, Schrope BA, Sugahara KN, Chabot JA, Wright JD. Perioperative and persistent opioid utilization following pancreatectomy in the United States. HPB (Oxford) 2022; 24:912-924. [PMID: 34815188 DOI: 10.1016/j.hpb.2021.10.021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/08/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Opioids are central to analgesia for pancreatic diseases. Individuals undergoing pancreatectomy have largely been excluded from studies of opioid use, because of malignancy or chronic use. Surgeons need to understand usage patterns, and practices that may incline patients toward persistent post-operative use. METHODS A retrospective study using IBM Watson Health MarketScan database examined patterns of peri-pancreatectomy opioid use between 2009 and 2017. Patients were grouped by opioid use 12 months to 31 days prior to pancreatectomy and followed for persistent use (refills 90-180 days postoperatively). Morphine milligram equivalents (MME) were calculated. Multivariable models explored associations between clinical characteristics, perioperative use and persistent use. RESULTS Opioids were used within the year prior to surgery by 35.6% of 8325 patients. The median MME for opioid naïve patients (400 mg) was a fraction of the 1800 mg prescribed to chronic opioid users for peri-operative analgesia. The rate of persistent opioid use was 15.1% among naïve, 27.2% among intermittent and 77.3% among chronic opioid users. Multivariable models demonstrated naïve and intermittent users who filled a prescription within 30 days prior to pancreatectomy, those who were prescribed total MME ≥1500 mg, and a ≥14 day supply were most at risk of persistent opioid use. Almost 23% of chronic users stopped using opioids post-operatively, suggesting surgery can provide relief. CONCLUSION Preoperative and persistent opioid use after pancreatectomy is substantially greater than expected based on other operations. Providers may mitigate this by recognizing the issue, managing expectations, and altering the timing and quantities of opioids prescribed.
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Affiliation(s)
- Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - Yongmei Y Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Dawn L Hershman
- Division of Hematology/Oncology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
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Thomas AS, Kwon W, Huang Y, Sharma RK, Schrope BA, Sugahara K, Chabot JA, Wright J, Kluger MD. Prevalence and Risk Factors for Endocrine Insufficiency in a National Sample of Patients Undergoing Partial Pancreatectomy. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.302] [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] [Indexed: 10/20/2022]
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Cawich SO, Kluger MD, Francis W, Deshpande RR, Mohammed F, Bonadie KO, Thomas DA, Pearce NW, Schrope BA. Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres. World J Gastrointest Surg 2021; 13:1122-1135. [PMID: 34754382 PMCID: PMC8554718 DOI: 10.4240/wjgs.v13.i10.1122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/19/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.
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Affiliation(s)
- Shamir O Cawich
- Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Michael D Kluger
- Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY 10032, United States
| | - Wesley Francis
- Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Fawwaz Mohammed
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Kimon O Bonadie
- Department of Surgery, Health Service Authority, Georgetown 915 GT, Cayman Islands
| | - Dexter A Thomas
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Neil W Pearce
- Department of Surgery, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Beth A Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, United States
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Witkowski P, Odorico J, Pyda J, Anteby R, Stratta RJ, Schrope BA, Hardy MA, Buse J, Leventhal JR, Cui W, Hussein S, Niederhaus S, Gaglia J, Desai CS, Wijkstrom M, Kandeel F, Bachul PJ, Becker YT, Wang LJ, Robertson RP, Olaitan OK, Kozlowski T, Abrams PL, Josephson MA, Andreoni KA, Harland RC, Kandaswamy R, Posselt AM, Szot GL, Ricordi C. Arguments against the Requirement of a Biological License Application for Human Pancreatic Islets: The Position Statement of the Islets for US Collaborative Presented during the FDA Advisory Committee Meeting. J Clin Med 2021; 10:jcm10132878. [PMID: 34209541 PMCID: PMC8269003 DOI: 10.3390/jcm10132878] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/25/2022] Open
Abstract
The Food and Drug Administration (FDA) has been regulating human islets for allotransplantation as a biologic drug in the US. Consequently, the requirement of a biological license application (BLA) approval before clinical use of islet transplantation as a standard of care procedure has stalled the development of the field for the last 20 years. Herein, we provide our commentary to the multiple FDA’s position papers and guidance for industry arguing that BLA requirement has been inappropriately applied to allogeneic islets, which was delivered to the FDA Cellular, Tissue and Gene Therapies Advisory Committee on 15 April 2021. We provided evidence that BLA requirement and drug related regulations are inadequate in reassuring islet product quality and potency as well as patient safety and clinical outcomes. As leaders in the field of transplantation and endocrinology under the “Islets for US Collaborative” designation, we examined the current regulatory status of islet transplantation in the US and identified several anticipated negative consequences of the BLA approval. In our commentary we also offer an alternative pathway for islet transplantation under the regulatory framework for organ transplantation, which would address deficiencies of in current system.
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Affiliation(s)
- Piotr Witkowski
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
- Correspondence: ; Tel.: +1-773-834-3524
| | - Jon Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI 53792, USA;
| | - Jordan Pyda
- Beth Israel Deaconess Medical Center, Department of Surgery, Harvard Medical School, Boston, MA 02115, USA;
| | - Roi Anteby
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Robert J. Stratta
- Section of Transplantation, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA;
| | - Beth A. Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - Mark A. Hardy
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; (B.A.S.); (M.A.H.)
| | - John Buse
- Division of Endocrinology, Department of Medicine, University of NC, Chapel Hill, NC 27516, USA;
| | - Joseph R. Leventhal
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL 60611, USA;
| | - Wanxing Cui
- Cell Therapy Manufacturing Facility, Georgetown University Hospital, Washington, DC 20007, USA;
| | - Shakir Hussein
- Detroit Medical Center, Department of Surgery, Wayne State School of Medicine, Detroit, MI 48201, USA;
| | - Silke Niederhaus
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Jason Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Chirag S. Desai
- Department of Surgery, Section of Transplantation, University of NC, Chapel Hill, NC 27516, USA;
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Fouad Kandeel
- Department of Translational Research and Cellular Therapeutics, Diabetes and Metabolism Research Institute, Beckman Research Institute of City of Hope, Duarte, CA 91010, USA;
| | - Piotr J. Bachul
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Yolanda Tai Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - Ling-Jia Wang
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (P.J.B.); (Y.T.B.); (L.-J.W.)
| | - R. Paul Robertson
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Washington, Seattle, WA 98133, USA;
| | | | - Tomasz Kozlowski
- Division of Transplantation, Department of Surgery, The University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Peter L. Abrams
- MedStar Georgetown Transplant Institute, Washington, DC 20007, USA;
| | | | - Kenneth A. Andreoni
- Department of Surgery, University of Florida, College of Medicine, Gainesville, FL 32610-0118, USA;
- Case Western Reserve University, Cleveland, OH 44106-5047, USA
| | - Robert C. Harland
- Department of Surgery, University of Arizona, Tucson, AZ 85711, USA;
| | - Raja Kandaswamy
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Andrew M. Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Gregory L. Szot
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA 94143, USA; (A.M.P.); (G.L.S.)
| | - Camillo Ricordi
- Diabetes Research Institute and Cell Transplant Center, University of Miami, Miami, FL 33136, USA;
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11
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Shaw K, Thomas AS, Rosario VL, Sugahara KN, Schrope BA, Chabot JA, Genkinger JM, Kwon W, Kluger MD. Long-term quality of life and global health following pancreatic surgery for benign and malignant pathologies. Surgery 2021; 170:917-924. [PMID: 33892953 DOI: 10.1016/j.surg.2021.03.023] [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: 12/16/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND While the frequency of pancreatic operations are increasing, understanding quality of life is still insufficient. The aim was to evaluate global health and quality of life of long-term survivors from a range of pancreatic operations using internationally validated instruments. METHODS Patients surviving longer than 5 years after pancreatic operations were surveyed using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Cancer-30 and Pancreatic Cancer-26 modules. Variables were analyzed according to demographic and clinical features. RESULTS Eighty patients completed questionnaires. The median follow-up was 9.3 years from the time of operation. The mean scores of global health status/quality of life, physical function, role function, emotional function, cognitive function, and social functioning were 73.9, 83.7, 84.6, 81.1, 80.2, and 86.3, respectively. The participants' reported quality of life was comparable or better than the general United States population. The summary score, which was defined as weighted average of function and symptom scores (excluding global health status/quality of life and financial impact scores), showed significant differences according to the level of education (70.1 no college vs 85.2 college and 85.7 grad school, P = .049), operation type (79.9 pancreatoduodenectomy vs 91.1 total, P = .043), additional endoscopic retrograde cholangiopancreatography (77.3 vs 86.0, P = .029), and additional abdominal operations related to the primary operation (79.0 vs 86.6, P = .026). CONCLUSION Long-term survivors of pancreatectomy had comparable or better global health status/quality of life, function scale, and lower symptom scores than the general population of the United States, though persistent gastrointestinal symptoms are common. These findings should help inform patients of the long-term consequences of pancreatectomy, so they can make better decisions especially when considering prophylactic operations.
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Affiliation(s)
- Kaitlin Shaw
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. https://twitter.com/KaitlinShawMPH
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Vilma L Rosario
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jeanine M Genkinger
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. https://twitter.com/drkluger
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12
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Mayeux SE, Kwon W, Rosario VL, Rossmer I, Schrope BA, Chabot JA, Kluger MD. Long-term health after pancreatic surgery: the view from 9.5 years. HPB (Oxford) 2021; 23:595-600. [PMID: 32988751 DOI: 10.1016/j.hpb.2020.08.017] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussing the impact of pancreatic surgery on long-term health is poorly understood, but necessary for informed consent. Given the increased number of pancreatic operations being performed annually, further investigation is necessary. METHODS Patients surviving longer than 5 years after pancreatic surgery were surveyed for postoperative hospitalizations, operations, pain, nutrition and diabetes. Variables were analyzed according to patient and peri-operative variables, and validated using medical records. RESULTS Eighty individuals completed the survey; median follow-up was 9.5 years (IQR:6.43,12.73). 47.5% underwent a pancreatoduodenectomy, and 25.0% a distal pancreatectomy; 40.0% had adenocarcinoma. 57.1% reported long-term weight loss, of which 65.9% was unintentional. While 1.3% took pancreatic enzymes before surgery, 38.8% utilized after. 12.5% had diabetes before, and 28.6% after surgery; 22 of 30 patients required insulin replacement therapy (73.3%). 41.3% reported hospitalizations, 17.5% required endoscopies and 28.8% additional operations after full recovery. Need for additional interventions were not related to pathology or post-operative complications, but were more common among patients undergoing a Whipple. CONCLUSION More than half of patients will have a long-term medical complication attributable to pancreatectomy. In comparison to the literature, it may be inferred that consequences occur within the first few years after surgery, and do not compound over time.
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Affiliation(s)
- Sophie E Mayeux
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Vilma L Rosario
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Irene Rossmer
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA.
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13
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Shaw K, Thomas AS, Rosario V, Kwon W, Schrope BA, Sugahara K, Chabot JA, Genkinger JM, Kluger MD. Long term quality of life amongst pancreatectomy patients with diabetes mellitus. Pancreatology 2021; 21:501-508. [PMID: 33509685 DOI: 10.1016/j.pan.2021.01.012] [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: 09/23/2020] [Revised: 12/01/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreatogenic diabetes is common after pancreatectomy, and the impact on quality of life (QOL) is poorly understood. The objective of this study was to investigate QOL between diabetic and non-diabetic patients at least five years after pancreatectomy. METHODS Patients were recruited from a prospectively maintained institutional database. Participants were administered the Audit of Diabetes-Dependent Quality of Life (ADDQOL). Quality of life was compared between diabetics and non-diabetics using validated European Organization for Research and Treatment of Cancer questionnaires. RESULTS 80 individuals completed surveys. 55% were female, 80% non-Hispanic white, 44% underwent Whipple, 48% were cystic neoplasms and 39% were adenocarcinoma. Diabetic patients (42.5%) reported comparable EORTC QLQ-C30 and Pan26 scores to non-diabetic patients. Pre-operative diabetic patients reported more dyspnea (p = 0.02) and greater pain (p = 0.02) than new-onset diabetics. Diabetic patients reported an overall ADDQOL quality of life score 'very good' (IQR: excellent, good) though felt life would be much better without diabetes (IQR: very much better, little better). While operation type was not influential, patients diagnosed with cystic neoplasms were almost twice as likely as those with other pathologies to report that life would be much better without diabetes (p < 0.01). CONCLUSION At a median of 9.3 years from pancreatic surgery, ADDQoL scores of patients were similar to cohorts of non-pancreatogenic diabetics in the general population. Patients without cancer were more likely to report that diabetes affected their overall QOL, regardless of operation. This study provides nuanced understanding of long-term QOL to improve the informed consent process and post-operative long-term care.
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Affiliation(s)
- Kaitlin Shaw
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Vilma Rosario
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Wooil Kwon
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Beth A Schrope
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Kazuki Sugahara
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - John A Chabot
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Jeanine M Genkinger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Michael D Kluger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
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14
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Desai CS, Szempruch KR, Vonderau JS, Chetboun M, Pattou F, Coates T, De Paep DL, Hawthorne WJ, Khan KM, de Koning EJP, Naziruddin B, Posselt A, Schrope BA, Wijkstrom M, Witkowski P, Shapiro AMJ. Anticoagulation practices in total pancreatectomy with autologous islet cell transplant patients: an international survey of clinical programs. Transpl Int 2021; 34:593-595. [PMID: 33452835 DOI: 10.1111/tri.13821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Chirag S Desai
- Department of Surgery, Abdominal Transplant, Chapel Hill, NC, USA
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | - Mikael Chetboun
- Department of General and Endocrine Surgery, CHU Lille and European Genomic Institute for Diabetes, University of Lille, Lille, France
| | - Francois Pattou
- Department of General and Endocrine Surgery, CHU Lille and European Genomic Institute for Diabetes, University of Lille, Lille, France
| | - Toby Coates
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Wayne J Hawthorne
- Department of Surgery, Western Clinical School, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Khalid M Khan
- Georgetown University Medical Center, Washington, DC, USA
| | - Eelco J P de Koning
- Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Andrew Posselt
- University of California San Francisco, San Francisco, CA, USA
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - A M James Shapiro
- Clinical Islet Transplant Program and Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
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15
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Schweber AB, Brooks C, Agarunov E, Sethi A, Poneros JM, Schrope BA, Kluger MD, Chabot JA, Gonda TA. New onset diabetes predicts progression of low risk pancreatic mucinous cysts. Pancreatology 2020; 20:1755-1763. [PMID: 33250091 DOI: 10.1016/j.pan.2020.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 05/22/2020] [Revised: 09/08/2020] [Accepted: 09/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with low-risk lesions require ongoing surveillance since the rate of progression to pancreatic cancer (PC), while small, is much greater than in the general population. Our objective was to study the relationship between new onset diabetes (NODM) and progression in patients with low risk mucinous cysts. METHODS We evaluated a prospectively maintained cohort of 442 patients with a suspected mucinous cyst without worrisome features (WF) or high-risk stigmata (HRS). Multivariable Cox models were developed for progression to WF and HRS, with diabetes status formulated as both time independent and dependent covariates. The adjusted cumulative risk of progression was calculated using the corrected group prognosis method. RESULTS The 5-year cumulative progression rates to WFs and HRS were 12.8 and 3.6%, respectively. After controlling for other risk factors, the development of NODM was strongly associated with progression to HRS (HR = 11.6; 95%CI, 3.5-57.7%), but not WF. Among patients with the smallest cysts (<10 mm) at baseline, those who developed NODM had a 5-year adjusted cumulative risk of progression to HRS of 8.6% (95%CI, 0.0%-20.2%), compared to only 0.8% (95%CI, 0.0%-2.3%) for patients without NODM. Among patients with the largest cysts (20-29 mm), those who developed NODM during surveillance had a 5-year adjusted cumulative risk of progression of 53.5% (95%CI, 19.6%-89.9%) compared to only 7.5% (95%CI, 1.6%-15.2%) for patients without NODM. CONCLUSION New onset diabetes may predict progression in patients with low risk mucinous cysts. Pending validation with large-scale studies, these findings support regular diabetes screening among patients surveilled for suspected IPMNs or MCNs.
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Affiliation(s)
- Adam B Schweber
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA
| | - Christian Brooks
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA; Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Emil Agarunov
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA
| | - Amrita Sethi
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA
| | - John M Poneros
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA
| | - Beth A Schrope
- Pancreas Center, Division of Surgery, Columbia University Irving Medical Center, NY, USA
| | - Michael D Kluger
- Pancreas Center, Division of Surgery, Columbia University Irving Medical Center, NY, USA
| | - John A Chabot
- Pancreas Center, Division of Surgery, Columbia University Irving Medical Center, NY, USA
| | - Tamas A Gonda
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, NY, USA; Division of Gastroenterology and Hepatology, New York University, New York, NY.
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16
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Weisberg SP, Carpenter DJ, Chait M, Dogra P, Gartrell-Corrado RD, Chen AX, Campbell S, Liu W, Saraf P, Snyder ME, Kubota M, Danzl NM, Schrope BA, Rabadan R, Saenger Y, Chen X, Farber DL. Tissue-Resident Memory T Cells Mediate Immune Homeostasis in the Human Pancreas through the PD-1/PD-L1 Pathway. Cell Rep 2020; 29:3916-3932.e5. [PMID: 31851923 PMCID: PMC6939378 DOI: 10.1016/j.celrep.2019.11.056] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/21/2019] [Accepted: 11/13/2019] [Indexed: 12/21/2022] Open
Abstract
Non-recirculating tissue-resident memory T cells (TRMs) are the predominant T cell subset in diverse tissue sites, where they mediate protective immune responses in situ. Here, we reveal a role for TRM in maintaining immune homeostasis in the human pancreas through interactions with resident macrophages and the PD-1/PD-L1 inhibitory pathway. Using tissues obtained from organ donors, we identify that pancreas T cells comprise CD8+PD-1hi TRMs, which are phenotypically, functionally, and transcriptionally distinct compared to TRMs in neighboring jejunum and lymph node sites. Pancreas TRMs cluster with resident macrophages throughout the exocrine areas; TRM effector functions are enhanced by macrophage-derived co-stimulation and attenuated by the PD-1/PD-L1 pathways. Conversely, in samples from chronic pancreatitis, TRMs exhibit reduced PD-1 expression and reduced interactions with macrophages. These findings suggest important roles for PD-1 and TRM-macrophage interactions in controlling tissue homeostasis and immune dysfunctions underlying inflammatory disease, with important implications for PD-1-based immunotherapies.
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Affiliation(s)
- Stuart P Weisberg
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Dustin J Carpenter
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA; Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Michael Chait
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032, USA; Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | - Pranay Dogra
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Andrew X Chen
- Department of Systems Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Sean Campbell
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | - Wei Liu
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | - Pooja Saraf
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | - Mark E Snyder
- Department of Medicine, Columbia University Medical Center, New York, NY 00132, USA
| | - Masaru Kubota
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Nichole M Danzl
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA
| | - Beth A Schrope
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Raul Rabadan
- Department of Systems Biology, Columbia University Medical Center, New York, NY 10032, USA
| | - Yvonne Saenger
- Department of Medicine, Columbia University Medical Center, New York, NY 00132, USA
| | - Xiaojuan Chen
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA; Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Donna L Farber
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032, USA; Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA; Department of Microbiology and Immunology, Columbia University Medical Center, New York, NY 10032, USA.
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17
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Nabavizadeh A, Payen T, Iuga AC, Sagalovskiy IR, Desrouilleres D, Saharkhiz N, Palermo CF, Sastra SA, Oberstein PE, Rosario V, Kluger MD, Schrope BA, Chabot JA, Olive KP, Konofagou EE. Noninvasive Young's modulus visualization of fibrosis progression and delineation of pancreatic ductal adenocarcinoma (PDAC) tumors using Harmonic Motion Elastography (HME) in vivo. Theranostics 2020; 10:4614-4626. [PMID: 32292518 PMCID: PMC7150482 DOI: 10.7150/thno.37965] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 06/27/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
Abstract
Background and aims: Poor specificity and predictive values of current cross-sectional radiological imaging methods in evaluation of pancreatic adenocarcinoma (PDAC) limit the clinical capability to accurately stage the tumor pre-operatively and provide optimal surgical treatment and improve patient outcomes. Methods: In this study, we applied Harmonic Motion Elastography (HME), a quantitative ultrasound-based imaging method to calculate Young's modulus (YM) in PDAC mouse models (n = 30) and human pancreatic resection specimens of PDAC (n=32). We compared the YM to the collagen assessment by Picrosirius red (PSR) stain on corresponding histologic sections. Results: HME is capable of differentiating between different levels of fibrosis in transgenic mice. In mice without pancreatic fibrosis, the measured YM was 4.2 ± 1.3 kPa, in fibrotic murine pancreata, YM was 5.5 ± 2.0 kPa and in murine PDAC tumors, YM was 11.3 ± 1.7 kPa. The corresponding PSR values were 2.0 ± 0.8 %, 9.8 ± 3.4 %, and 13.2 ± 1.2%, respectively. In addition, three regions within each human surgical PDAC specimen were assessed: tumor, which had both the highest Young's modulus (YM > 40 kPa) and collagen density (PSR > 40 %); non-neoplastic adjacent pancreas, which had the lowest Young's modulus (YM < 15 kPa) and collagen density (PSR < 10%) and a transitional peri-lesional region between the tumor and non-neoplastic pancreas with an intermediate value of measured Young's modulus (15 kPa < YM < 40 kPa) and collagen density (15% < PSR < 35 %). Conclusion: In conclusion, a non-invasive, quantitative imaging tool for detecting, staging and delineating PDAC tumor margins based on the change in collagen density was developed.
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18
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Payen T, Oberstein PE, Saharkhiz N, Palermo CF, Sastra SA, Han Y, Nabavizadeh A, Sagalovskiy IR, Orelli B, Rosario V, Desrouilleres D, Remotti H, Kluger MD, Schrope BA, Chabot JA, Iuga AC, Konofagou EE, Olive KP. Harmonic Motion Imaging of Pancreatic Tumor Stiffness Indicates Disease State and Treatment Response. Clin Cancer Res 2019; 26:1297-1308. [PMID: 31831559 DOI: 10.1158/1078-0432.ccr-18-3669] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 05/03/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDA) is a common, deadly cancer that is challenging both to diagnose and to manage. Its hallmark is an expansive, desmoplastic stroma characterized by high mechanical stiffness. In this study, we sought to leverage this feature of PDA for two purposes: differential diagnosis and monitoring of response to treatment. EXPERIMENTAL DESIGN Harmonic motion imaging (HMI) is a functional ultrasound technique that yields a quantitative relative measurement of stiffness suitable for comparisons between individuals and over time. We used HMI to quantify pancreatic stiffness in mouse models of pancreatitis and PDA as well as in a series of freshly resected human pancreatic cancer specimens. RESULTS In mice, we learned that stiffness increased during progression from preneoplasia to adenocarcinoma and also effectively distinguished PDA from several forms of pancreatitis. In human specimens, the distinction of tumors versus adjacent pancreatitis or normal pancreas tissue was even more stark. Moreover, in both mice and humans, stiffness increased in proportion to tumor size, indicating that tuning of mechanical stiffness is an ongoing process during tumor progression. Finally, using a brca2-mutant mouse model of PDA that is sensitive to cisplatin, we found that tissue stiffness decreases when tumors respond successfully to chemotherapy. Consistent with this observation, we found that tumor tissues from patients who had undergone neoadjuvant therapy were less stiff than those of untreated patients. CONCLUSIONS These findings support further development of HMI for clinical applications in disease staging and treatment response assessment in PDA.
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Affiliation(s)
- Thomas Payen
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Paul E Oberstein
- Division of Oncology, Department of Medicine, New York University Langone Medical Center, New York, New York
| | - Niloufar Saharkhiz
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Carmine F Palermo
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Stephen A Sastra
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yang Han
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Alireza Nabavizadeh
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York
| | - Irina R Sagalovskiy
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Barbara Orelli
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Vilma Rosario
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Deborah Desrouilleres
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Helen Remotti
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Michael D Kluger
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Beth A Schrope
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - John A Chabot
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alina C Iuga
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Elisa E Konofagou
- Department of Biomedical Engineering, Columbia University Irving Medical Center, New York, New York. .,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Kenneth P Olive
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York. .,Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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19
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Cui Y, Khanna LG, Saqi A, Crapanzano JP, Mitchell JM, Sethi A, Gonda TA, Kluger MD, Schrope BA, Allendorf J, Chabot JA, Poneros JM. The Role of Endoscopic Ultrasound-Guided Ki67 in the Management of Non-Functioning Pancreatic Neuroendocrine Tumors. Clin Endosc 2019; 53:213-220. [PMID: 31302988 PMCID: PMC7137561 DOI: 10.5946/ce.2019.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/06/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIMS The management of small, incidentally discovered nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) has been a matter of debate. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is a tool used to identify and risk-stratify PNETs. This study investigates the concordance rate of Ki67 grading between EUS-FNA and surgical pathology specimens in NFPNETs and whether certain NF-PNET characteristics are associated with disease recurrence and disease-related death. METHODS We retrospectively reviewed the clinical history, imaging, endoscopic findings, and pathology records of 37 cases of NFPNETs that underwent pre-operative EUS-FNA and surgical resection at a single academic medical center. RESULTS There was 73% concordance between Ki67 obtained from EUS-FNA cytology and surgical pathology specimens; concordance was the highest for low- and high-grade NF-PNETs. High-grade Ki67 NF-PNETs based on cytology (p=0.028) and histology (p=0.028) were associated with disease recurrence and disease-related death. Additionally, tumors with high-grade mitotic rate (p=0.005), tumor size >22.5 mm (p=0.104), and lymphovascular invasion (p=0.103) were more likely to have poor prognosis. CONCLUSION NF-PNETs with high-grade Ki67 on EUS-FNA have poor prognosis despite surgical resection. NF-PNETs with intermediate-grade Ki67 on EUS-FNA should be strongly considered for surgical resection. NF-PNETs with low-grade Ki67 on EUSFNA can be monitored without surgical intervention, up to tumor size 20 mm.
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Affiliation(s)
- YongYan Cui
- Department of Medicine, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - Lauren G Khanna
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University, New York, NY, USA
| | - Anjali Saqi
- Department of Pathology and Cell Biology, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - John P Crapanzano
- Department of Pathology and Cell Biology, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - James M Mitchell
- Department of Pathology and Cell Biology, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - Tamas A Gonda
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - Michael D Kluger
- Department of Surgery, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - Beth A Schrope
- Department of Surgery, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - John Allendorf
- Department of Surgery, New York University Winthrop Hospital, Mineola, NY, USA
| | - John A Chabot
- Department of Surgery, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
| | - John M Poneros
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Irving Medical Center, New York, NY, USA
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20
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Kluger MD, Chabot JA, Schrope BA. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2019; 166:951. [PMID: 30665618 DOI: 10.1016/j.surg.2018.12.001] [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: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Michael D Kluger
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY.
| | - John A Chabot
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY
| | - Beth A Schrope
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY
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21
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Kluger MD, Rashid MF, Rosario VL, Schrope BA, Steinman JA, Hecht EM, Chabot JA. Resection of Locally Advanced Pancreatic Cancer without Regression of Arterial Encasement After Modern-Era Neoadjuvant Therapy. J Gastrointest Surg 2018; 22:235-241. [PMID: 28895032 DOI: 10.1007/s11605-017-3556-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [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: 06/01/2017] [Accepted: 08/17/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Modern-era systemic therapy for locally advanced pancreatic adenocarcinoma (LAPC) offers improved survival relative to historical regimens but not necessarily improved radiographic downstaging to allow more patients to undergo resection. The aim of this study was to evaluate the survival, progression, and pathologic outcomes after resection of LAPC that did not regress from > 180 degrees arterial encasement after neoadjuvant therapy. METHODS Sixty-one LAPC patients were brought to the operating room after neoadjuvant therapy for NCCN-defined unresectable pancreatic cancer between 2012 and 2017. Pts were explored with intent of pancreatectomy and irreversible electroporation for margin extension; 5 (8%) had metastatic lesions on exploratory laparoscopy and were excluded from analyses. Imaging was re-examined to confirm LAPC prior to surgery. Data were analyzed from a prospective pancreatic cancer database. RESULTS Patients had arterial involvement of the celiac axis (37.5%) and/or superior mesenteric artery (42.9%) and/or an extended length of the common hepatic (n = 44.6%) artery. Twenty-nine males and 27 females, median 65 years of age, received neoadjuvant gemcitabine-based (58.9%) or FOLFIRINOX (35.7%) chemotherapy and stereotactic body (42.9%) or intensity-modulated (51.8%) radiation therapy. Median months from initiation of neoadjuvant therapy to surgery was 7.5. Sixty-one percent underwent Whipple, 21% distal, and 18% modified Appleby procedures; 57% patients underwent venous reconstruction. Ninety-day mortality was 2%. An R0 margin was achieved in 80%, and 53% were N0. Median overall and progression-free survival was 18.5 (95%CI 12.27-32.33) and 8.5 months (95%CI 6.0-15.0), respectively. One- and 3-year survival from surgery was 68.5% (95%CI 53.0-79.7) and 39.0% (95%CI 23.7-53.8), respectively. CONCLUSION With modern-era neoadjuvant therapy, R0 resections can be achieved in a majority of non-metastatic patients with locally advanced, unresectable disease based on cross-sectional imaging.
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Affiliation(s)
- Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - M Farzan Rashid
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Vilma L Rosario
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Jonathan A Steinman
- Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA. .,Division of GI & Endocrine Surgery, Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, 161 Fort Washington Ave-8th Floor, New York, NY, 10032, USA.
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22
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Rutkoski JD, Schrope BA, Lee BE. Survival Following Gastro-Left Ventricular Fistula in a Patient Post Roux-en-Y Gastric Bypass. Ann Thorac Surg 2016; 103:e51-e53. [PMID: 28007274 DOI: 10.1016/j.athoracsur.2016.06.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/11/2016] [Accepted: 06/08/2016] [Indexed: 11/25/2022]
Abstract
We report a case of a 55-year old woman with a prior roux-en-Y gastric bypass who survived after surgical repair of a gastro-left ventricular fistula.
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Affiliation(s)
- John D Rutkoski
- Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey
| | - Beth A Schrope
- Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey
| | - Benjamin E Lee
- The Daniel and Gloria Blumenthal Cancer Center, Paramus, New Jersey; The Division of Thoracic Surgery, Department of Surgery, The Valley Hospital/Valley Health System, Ridgewood, New Jersey.
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23
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Dorfman V, Verna EC, Poneros JM, Sethi A, Allendorf JD, Gress FG, Schrope BA, Chabot JA, Gonda TA. Progression of Incidental Intraductal Papillary Mucinous Neoplasms of the Pancreas in Liver Transplant Recipients. Pancreas 2016; 45:620-5. [PMID: 26495782 DOI: 10.1097/mpa.0000000000000510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Intraductal papillary mucinous neoplasms (IPMNs) are premalignant pancreatic cysts commonly found incidentally. Immunosuppression accelerates carcinogenesis.Thus, we aimed to compare IPMN progression in liver transplant (LT) recipients on chronic immunosuppression to progression among an immunocompetent population. METHODS We retrospectively assessed adult LT recipients between 2008 and 2014 for imaging evidence of IPMN. Diagnosis of IPMN was based on history, imaging, and cyst fluid analysis. The immunocompetent control group consisted of nontransplant patients from our pancreatic cyst surveillance program with IPMN under surveillance for greater than 12 months between 1997 and 2013. Four hundred fifty-four patients underwent LT in the study period and had cross-sectional imaging. RESULTS The prevalence of suspected IPMN was 6.6% (30 of 454). Compared with 131 controls, the transplant cohort was younger, with increased prevalence of diabetes and smoking. The prevalence of other risk factors for IPMN progression (history of pancreatitis, family history of pancreatic cancer) was similar. After an average follow-up of 31 months, most cysts increased in diameter, with a similar increase of dominant cyst (0.4 cm vs 0.5 cm; P = 0.6). Type of immunosuppression was not associated with the increased rate of cyst growth. CONCLUSIONS Our findings suggest that LT recipients with incidental IPMN can be managed under similar guidelines as immunocompetent patients.
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Affiliation(s)
- Valerie Dorfman
- From the *Albert Einstein College of Medicine, Bronx; †Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York; ‡Department of Surgery, Winthrop University Hospital, Mineola; and §Pancreas Center, Department of Surgery, Columbia University Medical Center, New York, NY
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24
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Kluger MD, Epelboym I, Schrope BA, Mahendraraj K, Hecht EM, Susman J, Weintraub JL, Chabot JA. Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients. Ann Surg Oncol 2015; 23:1736-43. [PMID: 26714959 DOI: 10.1245/s10434-015-5034-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.
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Affiliation(s)
- Michael D Kluger
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA.
| | - Irene Epelboym
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Beth A Schrope
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Krishnaraj Mahendraraj
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth M Hecht
- Division of Abdominal Imaging, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Jonathan Susman
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Joshua L Weintraub
- Division of Vascular and Interventional Radiology, Department of Radiology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Division of Gastrointestinal & Endocrine Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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25
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Epelboym I, DiNorcia J, Winner M, Lee MK, Lee JA, Schrope BA, Chabot JA, Allendorf JD. Neoadjuvant therapy and vascular resection during pancreaticoduodenectomy: shifting the survival curve for patients with locally advanced pancreatic cancer. World J Surg 2014; 38:1184-95. [PMID: 24305935 DOI: 10.1007/s00268-013-2384-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Neoadjuvant therapy and vascular resection may offer patients with locally advanced pancreatic cancer potential cure. METHODS We reviewed medical records of patients with ductal adenocarcinoma who underwent pancreaticoduodenectomy (PD) from 1992 through 2011. We identified patients who received neoadjuvant therapy (NA+) or required vascular resection (VR+) for locally advanced disease and compared outcomes to those who did not. RESULTS Of the 643 patients who were initially explored, 506 (143 NA+ and 363 NA- patients) ultimately underwent PD. There were no significant differences in R0 resection or morbidity. Mortality was higher in the NA+ versus NA- group (7.0 vs 3.0 %, p = 0.04). More NA+ patients underwent PD VR+ (p < 0.001). Among VR+ patients, neoadjuvant therapy resulted in significantly lower R1 resection. Among resected patients, survival of NA+ patients was significantly longer than both NA- patients (27.3 vs 19.7 months, p < 0.05) and patients abandoned because of locally advanced disease. Age, tumor grade, lymph node ratio, and R1 resection were independent predictors of poor survival. CONCLUSIONS Neoadjuvant therapy and vascular resection offer patients with locally advanced pancreatic cancer the chance for cure with acceptable morbidity and mortality. These patients have improved survival over patients deemed locally inoperable by traditional criteria.
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Affiliation(s)
- Irene Epelboym
- Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA,
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26
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Gawlas I, Epelboym I, Winner M, DiNorcia J, Woo Y, Lee JL, Schrope BA, Chabot JA, Allendorf JD. Short-term but not long-term loss of patency of venous reconstruction during pancreatic resection is associated with decreased survival. J Gastrointest Surg 2014; 18:75-82. [PMID: 24114682 DOI: 10.1007/s11605-013-2375-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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] [Received: 05/29/2013] [Accepted: 09/21/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic surgery with vascular reconstruction is increasingly performed to offer the benefits of surgical resection to patients with locally advanced disease. The short- and long-term patency rates and the clinical significance of thrombosis of such reconstructions are unknown. METHODS We reviewed pancreatectomies requiring venous reconstruction from 1994 to 2011. We sought to identify predictors of acute (within 30 days) and late thrombosis. We compared survival of patients with thrombosis to patients with patent reconstructions. RESULTS Of 203 pancreatectomies requiring venous reconstruction, acute thrombosis occurred in nine (4.4 %) cases and was associated with increased perioperative mortality (22.2 versus 4.6 %, p = 0.023). Even when nonfatal, acute thrombosis was associated with decreased median survival (7.1 versus 15.9 months, p = 0.011) and increased hazard of death (hazard ratio 8.6, confidence interval 3.7-19.9, p < 0.001). A late loss of patency was seen in 31.2 % of cases at a median of 9.5 months. Later loss of patency was not associated with decreased median survival or increased hazard of death. CONCLUSIONS Acute thrombosis of the portal venous reconstructions after pancreatectomy is associated with increased perioperative mortality and, even when nonfatal, is associated with decreased survival. Late loss of patency occurs in one-third of patients but does not affect survival.
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Affiliation(s)
- Irmina Gawlas
- Department of Surgery, Columbia University Medical Center, 8th Floor, 161 Fort Washington Avenue, New York, NY, 10032, USA,
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27
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Winner M, Epelboym I, Remotti H, Lee JL, Schrope BA, Chabot JA, Allendorf JD. Predictors of recurrence in intraductal papillary mucinous neoplasm: experience with 183 pancreatic resections. J Gastrointest Surg 2013; 17:1618-26. [PMID: 23813047 DOI: 10.1007/s11605-013-2242-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 05/31/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We examined long-term outcomes in patients with surgically treated intraductal papillary mucinous neoplasm (IPMN) to determine if any clinical or histologic features could predict risk of recurrent disease. METHODS We reviewed 183 margin-negative surgical resections performed for IPMN between 1994 and 2011 with documented postoperative abdominal imaging. We calculated time to recurrent disease as indicated by radiographic change and created a multivariable Cox proportional hazards model to assess the relationship between patient characteristics and histopathologic tumor features and disease recurrence. RESULTS Among patients with margin-negative resections and adequate imaging follow-up, we observed a recurrence rate of 13% over a median follow-up of 32.0 months. Individuals with invasive tumors on original pathology were more likely to recur (HR 5.2, 95% CI 2.2-12.2); however, original pathology did not predict disease severity on recurrence. Controlling for invasive pathology, no other histologic feature of the original tumor, including dysplasia at the surgical margin, predicted recurrence. Among non-invasive IPMN, pancreatitis was associated with disease recurrence (HR 3.6, 95% CI 1.2-10.7). CONCLUSIONS The frequency of recurrent disease in this population and the inability to predict recurrence argues for universal and continuous surveillance after resection for IPMN. The relationship between pancreatitis and disease recurrence should be investigated further.
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Affiliation(s)
- Megan Winner
- Department of Surgery, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
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28
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Gawlas I, Sethi M, Winner M, Epelboym I, Lee JL, Schrope BA, Chabot JA, Allendorf JD. Readmission after pancreatic resection is not an appropriate measure of quality. Ann Surg Oncol 2012; 20:1781-7. [PMID: 23224136 DOI: 10.1245/s10434-012-2763-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hospital readmission has been proposed as a metric for quality of medical and surgical care. We examined our institutional experience with readmission after pancreatic resection, and assessed factors predictive of readmission. METHODS We reviewed 787 pancreatic resections performed at a single institution between 2006 and 2010. Univariate and multivariate logistic regression models were used to assess the relationships between preoperative and postoperative characteristics and readmission. Reasons for hospital readmission were examined in detail. RESULTS We found the 30-day readmission rate after pancreatic resection to be 11.6 %. In univariate analysis, young age, pancreaticoduodenectomy versus other operations, open versus laparoscopic technique, fistula formation, the need for reoperation, and any complication during the index hospitalization were predictive of readmission. In multivariate analysis, only young age and postoperative complication were predictive of readmission. Vascular resection, postoperative ICU care, length of stay, and discharge disposition were not associated with readmission. The most common reasons for readmission were leaks, fistulas, abscesses, and wound infections (45.1 %), delayed gastric emptying (12.1 %), venous thrombosis (7.7 %), and GI bleeding (7.7 %). CONCLUSIONS We found the vast majority of readmissions after pancreatic resection were to manage complications related to the operation and were not due to poor coordination of care or poor discharge planning. Because evidence-based measures to prevent these surgical complications do not exist, we cannot support the use of readmission rates themselves as a quality indicator after pancreatic surgery.
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Affiliation(s)
- Irmina Gawlas
- Department of Surgery, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
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29
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Im GY, Stavropoulos SN, Schrope BA. An unusual cause of pancreatitis. Gastroenterology 2011; 141:e9-e10. [PMID: 22036782 DOI: 10.1053/j.gastro.2010.12.040] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 11/20/2010] [Accepted: 12/01/2010] [Indexed: 12/02/2022]
Affiliation(s)
- Gene Y Im
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop-University Hospital, Mineola, New York, USA
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30
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DiNorcia J, Ahmed L, Lee MK, Reavey PL, Yakaitis EA, Lee JA, Schrope BA, Chabot JA, Allendorf JD. Better preservation of endocrine function after central versus distal pancreatectomy for mid-gland lesions. Surgery 2011; 148:1247-54; discussion 1254-6. [PMID: 21134558 DOI: 10.1016/j.surg.2010.09.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 09/13/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Traditional resections for benign and low-grade malignant neoplasms of the mid pancreas result in loss of normal parenchyma that can cause pancreatic endocrine and exocrine insufficiency. Central pancreatectomy (CP) is a parenchyma-sparing option for such lesions. This study evaluates a single institution's experience with CP and compares outcomes with distal pancreatectomy (DP). METHODS We retrospectively collected data on CP patients from 1997 through 2009 and evaluated outcomes. In a subset of 50 patients, we performed a matched-pairs analysis to directly compare the short- and long-term outcomes of CP and DP. RESULTS Seventy-three patients underwent CP with a median operating room time of 254 minutes. Overall morbidity was 41.1% with pancreatic fistula in 20.5%. Mortality was 0%. There were no differences in fistula, morbidity, and mortality rates between the CP and DP groups. The CP group had resected for smaller lesions. CP patients had a lower rate of new-onset and worsening diabetes than DP patients (14% vs 46%; P = .003). Of new-onset and worsening diabetics, only 1 CP patient required insulin compared with 14 DP patients (P = .002). CONCLUSION CP is safe and effective for select neoplasms of the mid pancreas. Patients undergoing CP have markedly decreased insulin requirements compared with DP patients.
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Affiliation(s)
- Joseph DiNorcia
- Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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31
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DiNorcia J, Schrope BA, Lee MK, Reavey PL, Rosen SJ, Lee JA, Chabot JA, Allendorf JD. Laparoscopic distal pancreatectomy offers shorter hospital stays with fewer complications. J Gastrointest Surg 2010; 14:1804-12. [PMID: 20589446 PMCID: PMC3081877 DOI: 10.1007/s11605-010-1264-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study was to investigate short-term outcomes after LDP compared to open distal pancreatectomy (ODP) at a single, high-volume institution. METHODS We reviewed records of patients who underwent distal pancreatectomy (DP) and compared perioperative data between LDP and ODP. Continuous variables were compared using Student's t or Wilcoxon rank-sum tests. Categorical variables were compared using chi-square or Fisher's exact test. RESULTS A total of 360 patients underwent DP. Beginning in 2001, 95 were attempted, and 71 were completed laparoscopically with a 25.3% conversion rate. Compared to ODP, LDP had similar rates of splenic preservation, pancreatic fistula, and mortality. LDP had lower blood loss (150 vs. 900 mL, p < 0.01), smaller tumor size (2.5 vs. 3.6 cm, p < 0.01), and shorter length of resected pancreas (7.7 vs. 10.0 cm, p < 0.01). LDP had fewer complications (28.2% vs. 43.8%, p = 0.02) as well as shorter hospital stays (5 vs. 6 days, p < 0.01). CONCLUSIONS LDP can be performed safely and effectively in patients with benign or low-grade malignant neoplasms of the distal pancreas. When feasible in selected patients, LDP offers fewer complications and shorter hospital stays.
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Affiliation(s)
- Joseph DiNorcia
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Lee MK, Dinorcia J, Reavey PL, Holden MM, Genkinger JM, Lee JA, Schrope BA, Chabot JA, Allendorf JD. Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older. J Gastrointest Surg 2010; 14:1838-46. [PMID: 20824366 DOI: 10.1007/s11605-010-1345-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 08/23/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgery offers the only chance for cure in patients with pancreatic cancer, and a growing number of elderly patients are being offered resection. We examined outcomes after pancreaticoduodenectomy in patients 80 years and older. METHODS We retrospectively collected data on pancreaticoduodenectomy patients from 1992 to 2009 to compare outcomes between patients older and younger than 80 years. Variables were compared using t-, Wilcoxon rank-sum, or Fisher's exact tests. Survival was compared using Kaplan-Meier analysis and log-rank test. RESULTS Patients 80 years and older who underwent pancreaticoduodenectomy were similar with respect to sex, race, blood loss, operative times, reoperation, length of stay, and readmission compared to younger patients. There were no differences in overall complications (47% vs. 51%, p = 0.54), major complications (19% vs. 25%, p = 0.25), and mortality (5% vs. 4%, p = 0.53) when comparing older to younger patients. In a subset who underwent pancreaticoduodenectomy for ductal adenocarcinoma, older patients (n = 45) had a median survival time of 11.6 months compared to 18.1 months in younger patients (n = 346; p < 0.01). CONCLUSION Pancreaticoduodenectomy can be performed safely in select patients 80 years and older. Age alone should not dissuade surgeons from offering patients resection, though elderly patients with pancreatic ductal adenocarcinoma appear to have shorter survival than younger patients with the same disease.
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Affiliation(s)
- Minna K Lee
- Department of Surgery, College of Physicians and Surgeons, Columbia University, 161 Fort Washington Avenue, Suite 820, New York, NY 10032-3784, USA
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DiNorcia J, Lee MK, Reavey PL, Genkinger JM, Lee JA, Schrope BA, Chabot JA, Allendorf JD. One hundred thirty resections for pancreatic neuroendocrine tumor: evaluating the impact of minimally invasive and parenchyma-sparing techniques. J Gastrointest Surg 2010; 14:1536-46. [PMID: 20824378 DOI: 10.1007/s11605-010-1319-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 08/09/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increasingly, surgeons apply minimally invasive and parenchyma-sparing techniques to the management of pancreatic neuroendocrine tumor (PNET). The aim of this study was to evaluate the impact of these approaches on patient outcomes. METHODS We retrospectively collected data on patients with PNET and compared perioperative and pathologic variables. Survival was analyzed using the Kaplan-Meier method. Factors influencing survival were evaluated using a Cox proportional hazards model. RESULTS One hundred thirty patients underwent resection for PNET. Traditional resections included 43 pancreaticoduodenectomies (PD), 38 open distal pancreatectomies (DP), and four total pancreatectomies. Minimally invasive and parenchyma-sparing resections included 25 laparoscopic DP, 11 central pancreatectomies, five enucleations, three partial pancreatectomies, and one laparoscopic-assisted PD. Compared to traditional resections, the minimally invasive and parenchyma-sparing resections had shorter hospital stays. By univariate analysis of neuroendocrine carcinoma, liver metastases and positive resection margins correlated with poor survival. There was an increase in minimally invasive or parenchyma-sparing resections over the study period with no differences in morbidity, mortality, or survival. CONCLUSION In this series, there has been a significant increase in minimally invasive and parenchyma-sparing techniques for PNET. This shift did not increase morbidity or compromise survival. In addition, minimally invasive and parenchyma-sparing operations yielded shorter hospital stays.
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Affiliation(s)
- Joseph DiNorcia
- College of Physicians and Surgeons, Department of Surgery, Columbia University, 161 Fort Washington Avenue, Suite 820, New York, NY 10032, USA
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Bagloo MB, Purohit M, DiGiorgi M, Ude AO, Schrope BA, Bessler M. P-110: Conversion to gastric bypass after failed lap band results in weight loss equal to primary gastric bypass. Surg Obes Relat Dis 2010. [DOI: 10.1016/j.soard.2010.03.154] [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] [Indexed: 11/26/2022]
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Allendorf JD, Schrope BA, Lauerman MH, Inabnet WB, Chabot JA. Postoperative glycemic control after central pancreatectomy for mid-gland lesions. World J Surg 2007; 31:164-8; discussion 169-70. [PMID: 17171499 DOI: 10.1007/s00268-005-0382-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [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: 12/12/2022]
Abstract
INTRODUCTION Patients undergoing partial pancreatectomy are at risk for developing surgically induced diabetes. Patients with lesions in the neck and body of the pancreas are at increased risk because traditional resectional approaches (pancreaticoduodenectomy or distal pancreatectomy) must be extended to remove the tumor with adequate margins. Increasingly, we have been performing pancreatic parenchyma-sparing resections (central pancreatectomy with pancreaticogastrostomy) in an effort to reduce the risk of postpancreatectomy endocrine insufficiency. METHODS The operative records of patients who underwent pancreatectomy at our institution from 1999 to 2005 were reviewed. We identified 26 patients who underwent central pancreatectomy with pancreaticogastrostomy reconstruction for cystic lesions (n = 23), neuroendocrine tumors (n = 2), and Frantz's tumor (n = 1). Charts were reviewed for patient demographics, volume of resection, complications, and evaluation of postoperative glycemic control. RESULTS The mean follow-up was 33 months (range 3-72 months). The average volume of pancreas resected was 49.6 +/- 38.6 cm(3), and the mean diameter of the lesions was 2.6 +/- 1.5 cm. Nine complications occurred in eight patients (overall morbidity 31%), and the average length of stay was 6.9 +/- 2.7 days. Pancreatic leaks (n = 2; 7.7%) were successfully managed nonoperatively. There was no operative mortality, and there has been no tumor recurrence. None of the patients were diabetic preoperatively. Postoperatively, two (7.7%) developed endocrine insufficiency with a mean postoperative hemoglobin A1c (HbA1c) value of 7.65%. Neither patient has required exogenous insulin. HbA1c in the remaining patients was 5.9% +/- 0.5%. CONCLUSIONS Pancreatic parenchyma-sparing surgery for lesions in the midportion of the gland can be performed with acceptable morbidity. Postoperative glycemic control after pancreatic parenchyma-sparing surgery compares favorably with that reported for patients with traditional resections.
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Affiliation(s)
- John D Allendorf
- Department of Surgery, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032, USA.
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Schrope BA, Daud A, Bessler M. Unintentional creation of reverse peristaltic alimentary limb during Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2006; 2:478-82. [PMID: 16925386 DOI: 10.1016/j.soard.2006.04.231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 04/20/2006] [Accepted: 04/20/2006] [Indexed: 11/26/2022]
Affiliation(s)
- B A Schrope
- Center for Obesity Surgery, New York-Presbyterian Hospital and Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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Daud A, Inabnet WB, Digiorgi MF, Olivero-Rivera L, Schrope BA, Davis D, Bessler M. Effect of bariatric surgery in elderly patients. Surg Obes Relat Dis 2005. [DOI: 10.1016/j.soard.2005.03.099] [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] [Indexed: 10/25/2022]
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Fogelman DR, Chen J, Chabot JA, Allendorf JD, Schrope BA, Ennis RD, Schreibman SM, Fine RL. The evolution of adjuvant and neoadjuvant chemotherapy and radiation for advanced pancreatic cancer: from 5-fluorouracil to GTX. Surg Oncol Clin N Am 2004; 13:711-35, x. [PMID: 15350944 DOI: 10.1016/j.soc.2004.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [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: 10/25/2022]
Abstract
This article reviews the relevant literature and reports on The Columbia University Medical Center experience with chemoradiation for pancreatic cancer.
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Affiliation(s)
- David R Fogelman
- Experimental Therapeutics Program, Division of Medical Oncology, Department of Medicine, Columbia University Medical Center, 650 West 168th Street, New York, NY 10032, USA
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Abstract
In vitro and in vivo testing of a recently introduced method of evaluating blood perfusion is presented, where the Doppler shift of the second harmonic component of the backscattered echo is measured. Central to this measurement is the administration of a galactose-based contrast agent (Schering AG, Berlin, Germany, SHU-508 or derivative) which has been shown in vitro to exhibit extraordinary nonlinear backscattering properties. Two types of experiments are described: in vitro studies on excised sheep kidneys and in vivo studies on living rabbits. In the animal model, blood perfusion was manipulated by various mechanisms to obtain some indication of the quantitative ability of the measurement. Comparisons between measurements made at the fundamental component of the backscattered echo and at the second harmonic show that use of the second harmonic measurement results in a much improved ratio of blood echo intensity to tissue echo intensity (signal-to-clutter ratio), allowing detection of blood flowing in smaller vessels and opening up the potential for real-time determination of blood volume fluctuations in tissue.
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