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Van Veldhuisen CL, Leseman CA, De Rijk FEM, Dekker EN, Wellens MJ, Michiels N, Stommel MWJ, Krikke C, Hofker HS, Mieog JSD, Bouwense SA, Van Eijck CH, Groot Koerkamp B, Haen R, Boermeester MA, Busch OR, Van Santvoort HC, Besselink MG. Nationwide Outcome of Tailored Surgery for Symptomatic Chronic Pancreatitis based on Pancreatic Morphology: Validation of the International guidelines. Ann Surg 2023:00000658-990000000-00724. [PMID: 38088187 DOI: 10.1097/sla.0000000000006176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To determine the nationwide use and outcome of tailored surgical treatment for symptomatic chronic pancreatitis (CP) as advised by recent guidelines. SUMMARY BACKGROUND DATA Randomized trials have shown that surgery is superior to endoscopy in patients with symptomatic CP, although endoscopy remains popular Recent guidelines advice to "tailor surgery" based on pancreatic morphology meaning that the least extensive procedure should be selected based on pancreatic morphology. However, nationwide, and multicenter studies On tailored surgery for symptomatic CP are lacking. METHODS Nationwide multicenter retrospective analysis of consecutive patients undergoing surgical treatment for symptomatic CP in all seven Dutch university medical centers (2010-2020). Outcomes included volume trend, major complications, 90-day mortality, postoperative opioid use and clinically relevant pain relief. Surgical treatment was tailored based on the size of the main pancreatic duct and pancreatic head (e.g. surgical drainage for a dilated pancreatic duct, and normal size pancreatic head). RESULTS Overall, 381 patients underwent surgery for CP: 127 surgical drainage procedures ( 33%; mostly extended lateral pancreaticojejunostomy), 129 duodenum-preserving pancreatic head resections (DPPHR, 34%, mostly Frey), and 125 formal pancreatic resections (33%, mostly distal pancreatectomy). The annual surgical volume increased slightly (Pearson r=0.744). Mortality (90-day) occurred in 6 patients (2%), and was non-significantly lower after surgical drainage (0%, 3%, 2%; P =0.139). Major complications (12%, 24%, 26%; P =0.012), postoperative pancreatic fistula grade B/C (0%, 3%, 22%; P =0.038), surgical reintervention (4%, 16%, 12%; P =0.006), and endocrine insufficiency ( 14%, 21%, 43%; P <0.001) occurred less often after surgical drainage. After a median follow-up of 11 months [IQR 3-23] good rates of clinically relevant pain relief ( 83%, 69%, 80%; P =0.082) were observed and 81% of opioid users had stopped using (83%, 78%, 84%, P =0.496). CONCLUSION The use of surgery for symptomatic CP increased over the study period. Drainage procedures were associated with the best safety profile and excellent functional outcome, highlighting the importance of tailoring surgery based on pancreatic morphology.
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Affiliation(s)
- Charlotte L Van Veldhuisen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
- Department of Research and Development, St. Antonius Hospital, Nieuwegein
| | - Charlotte A Leseman
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Fleur E M De Rijk
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - E Nicole Dekker
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam
| | - Martine J Wellens
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Centre, Leiden
| | | | - Christina Krikke
- Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen
| | - H Sijbrand Hofker
- Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht
| | - Casper H Van Eijck
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Bas Groot Koerkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Roel Haen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Marja A Boermeester
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Hjalmar C Van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein
- Department of Surgery, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht All: The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
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Versteijne E, Suker M, Groen JV, Besselink MG, Bonsing BA, Bosscha K, Busch OR, de Hingh IHJT, de Jong KP, Molenaar IQ, van Santvoort HC, Verkooijen HM, Van Eijck CH, van Tienhoven G. External Validity of the Multicenter Randomized PREOPANC Trial on Neoadjuvant Chemoradiotherapy in Pancreatic Cancer: Outcome of Eligible but Nonrandomized Patients. Ann Surg 2022; 275:972-978. [PMID: 33273349 DOI: 10.1097/sla.0000000000004364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/28/2023]
Abstract
OBJECTIVES To investigate the accrual proportion and patients' reasons for not participating in the PREOPANC trial on neoadjuvant chemoradiotherapy versus immediate surgery in resectable and borderline resectable pancreatic cancer, and to compare these patients' outcomes with those of patients who had been randomized in the trial. SUMMARY OF BACKGROUND DATA The external validity of multicenter randomized trials in cancer treatment has been criticized for suboptimal non-representative inclusion. In trials, it is unclear how outcomes compare between randomized and nonrandomized patients. METHODS At 8 of 16 participant centers, this multicenter observational study identified validation patients, who had been eligible but not randomized during recruitment for the PREOPANC trial. We assessed the accrual proportion, investigated their most common reasons for not participating in the trial, and compared resection rates, radical (R0) resection rates, and overall survival between the validation patients and PREOPANC patients, who had been randomized in the trial to immediate surgery. RESULTS In total, 455 patients had been eligible during the recruitment period, 151 of whom (33%) had been randomized. Fifty-five percent of the 304 validation patients had refused to participate. Median overall survival in the validation group was 15.2 months, against 15.5 months in the PREOPANC group (P = 1.00). The respective resection rates (76% vs 73%) and R0 resection rates (51% vs 46%) did not differ between the groups. CONCLUSIONS The PREOPANC trial included a reasonable percentage of 33% of eligible patients. In terms of the outcomes survival, resection rate, and R0 resection rate, this appeared to be a representative group.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jesse V Groen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Koert P de Jong
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, RAKU, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Casper H Van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Onete VG, Besselink MG, Salsbach CM, Van Eijck CH, Busch OR, Gouma DJ, de Hingh IH, Sieders E, Dejong CH, Offerhaus JG, Molenaar IQ. Impact of centralization of pancreatoduodenectomy on reported radical resections rates in a nationwide pathology database. HPB (Oxford) 2015; 17:736-42. [PMID: 26037776 PMCID: PMC4527860 DOI: 10.1111/hpb.12425] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 01/02/2015] [Accepted: 04/04/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Centralization of a pancreatoduodenectomy (PD) leads to a lower post-operative mortality, but is unclear whether it also leads to improved radical (R0) or overall resection rates. METHODS Between 2004 and 2009, pathology reports of 1736 PDs for pancreatic and peri-ampullary neoplasms from a nationwide pathology database were analysed. Pre-malignant lesions were excluded. High-volume hospitals were defined as performing ≥ 20 PDs annually. The relationship between R0 resections, PD-volume trends, quality of pathology reports and hospital volume was analysed. RESULTS During the study period, the number of hospitals performing PDs decreased from 39 to 23. High-volume hospitals reported more R0 resections in the pancreatic head and distal bile duct tumours than low-volume hospitals (60% versus 54%, P = 0.035) although they operated on more advanced (T3/T4) tumours (72% versus 58%, P < 0.001). The number of PDs increased from 258 in 2004 to 394 in 2009 which was partly explained by increased overall resection rates of pancreatic head and distal bile duct tumours (11.2% in 2004 versus 17.5% in 2009, P < 0.001). The overall reported R0 resection rate of pancreatic head and distal bile duct tumours increased (6% in 2004 versus 11% in 2009, P < 0.001). Pathology reports of low-volume hospitals lacked more data including tumour stage (25% versus 15%, P < 0.001). CONCLUSIONS Centralization of PD was associated with both higher resection rates and more reported R0 resections. The impact of this finding on overall survival should be further assessed.
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Affiliation(s)
- Veronica G Onete
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands,Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands,Correspondence Marc G. Besselink, Dutch Pancreatic Cancer Group, Academic Medical Center Amsterdam, Department of Surgery, Room G4-196, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel.: +31-20-5669111. Fax: +31-20-5669243. E-mail:
| | - Chanielle M Salsbach
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands,Department of Surgery, Erasmus Medical CenterRotterdam, The Netherlands
| | | | - Olivier R Busch
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical CenterAmsterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital EindhovenEindhoven, The Netherlands
| | - Egbert Sieders
- Department of Surgery, University Medical Center GroningenGroningen, The Netherlands
| | - Cornelis H Dejong
- Department of Surgery, University Medical Center Maastricht, Maastricht and NUTRIM School for Nutrition, Toxicology and MetabolismMaastricht, The Netherlands
| | - Johan G Offerhaus
- Department of Pathology, University Medical Center UtrechtUtrecht, The Netherlands,Department of Pathology, Academic Medical Center AmsterdamAmsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center UtrechtUtrecht, The Netherlands
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