Quality of Life and Gastrointestinal Symptoms in Long-term Survivors of Pancreatic Cancer Following Pancreatoduodenectomy

OBJECTIVE

To describe long-term quality of life (QOL) and gastrointestinal (GI) symptoms in patients who underwent pancreatoduodenectomy for pancreatic cancer in the modern era.

BACKGROUND

As advances in pancreatic cancer management improve outcomes, it is essential to assess long-term patient-reported outcomes after surgery.

METHODS

Patients who underwent curative intent pancreatoduodenectomy for pancreatic cancer between January 2011 and June 2019 from a single center were identified. Patients alive ≥3 years after surgery were considered long-term survivors (LTS). LTS who were alive in June 2022 received a 55-question survey to assess their QOL (EORTC-QLQ-C30) and GI symptoms (EORTC-PAN26 and Problem Areas in Diabetes Questionnaire). Responses were compared against population norms. Clinicodemographic characteristics in LTS versus non-LTS and survey completion were compared.

RESULTS

Six hundred seventy-two patients underwent pancreatoduodenectomy for pancreatic cancer; 340 were LTS. One hundred thirty-seven patients of the 238 eligible to complete the survey responded (response rate: 58%). Compared to the US general population, LTS reported significantly higher QOL (75 vs 64; P <0.001), less nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and constipation, but more diarrhea (all P <0.001). Most patients (n=136/137, 99%) reported experiencing postoperative GI symptoms related to pancreatic insufficiency (n=71/135, 53%), reflux (n=61/135, 45%), and delayed gastric emptying (n=31/136, 23%). Most patients (n=113/136, 83%) reported that digestive symptoms overall had little to no impact on QOL, and 91% (n=124/136) would undergo surgery again.

CONCLUSIONS

Despite known long-term complications following pancreatoduodenectomy, cancer survivors appear to have excellent QOL. Specific long-term gastrointestinal symptoms data should be utilized for preoperative education and follow-up planning.

Frequency of an intrathecal IgM synthesis and MRZ reaction in children with MS

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the CNS. An intrathecal IgM synthesis is associated with a more rapid progression of MS and the intrathecal immune response to measles -, rubella -and varicella zoster virus (MRZR) which, if present, increases the likelihood of a diagnosis of MS in adults.

OBJECTIVE

To evaluate the frequency of an intrathecal IgM synthesis and MRZR in children with MS. MethodsChildren with MS and a data set including clinical and treatment history, MRI at onset, in addition to a CSF analysis, and determination of antibody index (AI) of measles, rubella, and zoster antibodies, were eligible. The presence of an intrathecal IgM synthesis and/or a positive MRZ reaction were compared to biomarkers of a more progressive disease course.

RESULTS

In 75 children with MS, OCBs were present in 93.3 %). 49,2 % experienced their first relapse within 6 months. 50.7 % had a total lesion load of more than 10 lesions in the first brain MRI. Spinal lesions were identified in 64 %. 23.5 % had a positive MRZR and 40.3 % an intrathecal IgM synthesis. No significant associations were detected between the presence of an intrathecal IgM synthesis and MRZR and parameters including the relapse rate in the first two years.

CONCLUSION

An intrathecal IgM synthesis and a positive MRZR are found in a subset of MS children but are not associated with markers associated with a poor prognosis.

The "double-fired" gastro-jejunostomy as a form of improved efficiency during Whipple procedure

BACKGROUND

Gastro-jejunostomy (GJ) after pylorus-resecting pancreatoduodenectomy (PD) is most commonly performed in a hand-sewn fashion. Intestinal stapled anastomosis are reported to be as effective as hand-sewn in terms of patency and risk of leakage in other indications. However, the use of a stapled gastro-jejunostomy hasn't been fully assessed in PD. The aim of the present technical report is to evaluate functional outcomes of stapled GJ during PD, its associated effect on operative time and related complications.

METHODS

The institutional database for pancreatic duct adenocarcinoma (PDAC) was retrospectically reviewed. Pylorus resecting open PD without vascular or multivisceral resections were considered for the analysis. The incidence of clinically significant delayed gastric emptying (DGE from the International Stufy Group of Pancreatic Surgery (ISGPS) grade B and C), other complications, operative time and overall hospitalization were evaluated.

RESULTS

Over a 10-years study period, 1182 PD for adenocarcinoma were performed and recorded in the database. 243 open Whipple procedures with no vascular and with no associated multivisceral resections were available and constituted the study population. Hand-sewn (HS) anastomosis was performed in 175 (72 %), stapled anastomosis (St) in 68 (28 %). No significant differences in baseline characteristics were observed between the two groups, with the exception of a higher rate of neoadjuvant chemotherapy in the HS group (74 % St vs. 86 % HS, p = 0.025). Intraoperatively, a significantly reduced median operative time in the St group was observed (248 min St vs. 370 mins HS, p < 0.001). Post-operatively, rates of clinically relevant delayed gastric emptying (7 % St vs. 14 % HS, p = 0.140), clinically relevant pancreatic fistula (10 % St, 15 % HS, p = 0.300), median length of stay (7 days for each group, p = 0.289), post-pancreatectomy hemorrhage (4.4 % St vs. 6.3 % HS, p = 0.415) and complication rate (22 % St vs. 34 % HS, p = 0.064) were similar between groups. However, readmission rates were significantly lower after St GJ (13.2 % St vs 29.7 % HS, p = 0.008).

CONCLUSION

Our results indicate that a stapled GJ anastomosis during a standard Whipple procedure is non-inferior to a hand-sewn GJ, with a comparable rate of DGE and no increase of gastrointestinal related long term complications. Further, a stapled GJ anastomosis might be associated with reduced operative times.

Outpatient surgery benchmarks and practice variation patterns: Case controlled study

BACKGROUND

Despite numerous potential benefits of outpatient surgery, there is currently a lack of national benchmarking data available for hospitals and surgeons to compare their own outcomes as they transition toward outpatient surgery.

MATERIALS AND METHODS

Patients who underwent 14 common general surgery operations from 2016-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Operations were selected based on frequency and the ability to be performed both in- and outpatient. Postoperative complications and readmissions were compared between patients who underwent inpatient vs outpatient surgery. After adjusting for patient comorbidities, multivariable models assessed the effect of patient characteristics on the odds of experiencing postoperative complications. A separate multiinstitutional study of 21 affiliated hospitals assessed practice variation.

RESULTS

In 13 of the 14 studied procedures, complications were lower for patients who were selected for outpatient surgery (all P<0.01); minimally invasive (MIS) adrenalectomy showed no difference (P=0.61). Multivariable analysis confirmed these findings; the odds of experiencing any adverse events were lower following outpatient surgery in all operations but MIS adrenalectomy (OR 0.97; 95% CI 0.47-2.02). Analysis of institutional practices demonstrated variation in the rate of outpatient surgery in certain breast, endocrine, and hernia repair operations.

CONCLUSIONS

Institutional practice patterns may explain the national variation in the rate of outpatient surgery. While the present data does not support the adoption of outpatient surgery to less optimal candidates, addressing unexplained practice variations could result in improved utilization of outpatient surgery.

Tumor-Informed Circulating Tumor DNA for Minimal Residual Disease Detection in the Management of Colorectal Cancer

PURPOSE

Recurrence after curative-intent treatment occurs in 20%-50% of patients with stage II-IV colorectal cancer (CRC), underscoring the need for early detection of minimal residual disease (MRD) using circulating tumor DNA (ctDNA). Here, we examined the pattern of use of a tumor-informed ctDNA assay in CRC MRD monitoring in routine clinical practice at Mayo Clinic, Rochester.

METHODS

We conducted a retrospective analysis of health records of patients with CRC who had at least one tumor-informed ctDNA assay from May 2019 through July 1, 2022. Recurrence was defined as radiographic evidence of disease. Descriptive characteristics of the cohort, ctDNA results, and subsequent interventions were recorded.

RESULTS

Of the 120 patients included, the median age at diagnosis was 67 years, 46% were female, and 94% were White. At diagnosis, 10 patients had stage I, 23 stage II, 60 stage III, and 25 stage IV disease. Of 476 ctDNA assays performed, 70% were performed in patients who had recurrent disease most commonly to monitor the effectiveness of therapeutic interventions and 16% resulted in a change in clinical decision making. There were 110 recurrences identified in 62 patients, as some patients experienced more than one recurrence over time. Compared with serum carcinoembryonic antigen levels, ctDNA results correlated better with radiologic imaging.

CONCLUSION

Routine ctDNA monitoring for MRD detection has been adopted in clinical practice; however, 84% of ctDNA assays performed did not result in a change in clinical management. This suggests the need for further clinical research data to guide routine clinical use of ctDNA MRD testing in CRC.

Accuracy of DOTATATE PET imaging in the preoperative planning of small bowel neuroendocrine tumor resection

BACKGROUND AND OBJECTIVES

We assessed the accuracy of preoperative gallium-68 DOTA-Tyr3-octreotate (DOTATATE) positron emission tomography (PET) imaging in estimating multifocality and nodal metastases of small bowel neuroendocrine tumors (sbNETs).

METHODS

A multicenter analysis was performed on patients with sbNETs who underwent preoperative DOTATATE PET imaging and surgical resection, with manual palpation of the entire length of the small bowel, between January 2016 and August 2022. Preoperative imaging reports and blinded secondary imaging reviews were compared to the final postoperative pathology reports. Descriptive statistics were applied.

RESULTS

One-hundred and four patients met inclusion criteria. Pathology showed 53 (51%) patients had multifocal sbNETs and 96 (92%) had nodal metastases. The original preoperative DOTATATE PET imaging identified multifocal sbNET in 28 (27%) patients and lymph node (LN) metastases in 80 (77%) patients. Based on original radiology reports, sensitivity for multifocal sbNET identification was 45%, specificity was 92%, positive predictive value (PPV) was 86%, and negative predictive value (NPV) was 62%. For the identification of LN metastases, sensitivity was 82%, specificity was 88%, PPV was 99%, and NPV was 29%.

CONCLUSIONS

Although DOTATATE PET imaging is specific and relatively accurate, sensitivity and NPV are insufficient to guide surgical planning. Preoperative use should not replace open palpation to identify additional synchronous lesions or to omit regional lymphadenectomy.

[Cognitive Development in Children with Benign Rolandic Epilepsy of Childhood with Centrotemporal Spikes - Results of a Current Systematic Database Search]

Benign Rolandic Epilepsy (BRE) is one of the most common epilepsy syndromes in childhood. Although global intellectual performance is typically normal in BRE-patients, problems were found in specific cognitive domains. To summarize recent empirical findings concerning cognitive development in children with BRE a systematic literature search of clinical studies published between 2009 and 2015 was performed. 19 studies of relevance were found.In most recent studies children with BRE consistently showed general intellectual performance within the normal range. However, in two of the studies patients showed a significantly poorer (but still normal) performance in comparison to controls. The studies provide clear indications for a high prevalence of impairments in language (10 out of 12 studies) and academic performance (6 out of 8 studies) in children with BRE. Regarding deficits in other cognitive domains (attention, memory, visual/auditory perception, executive functions) current findings are inconsistent. In addition, no clear results are found in studies examining cognitive development after remission of BRE. Studies on the relationship between selected clinical/electroencephalographic characteristics (e. g. EEG-patterns, focus lateralization) and cognitive performance and studies on potential benefits of anti-epileptic therapy for cognitive functions also have not yielded consistent results. Studies using fMRI and evoked potentials provide evidence for functional reorganization of neural networks in BRE.Due to the developmental risks in children with BRE early cognitive assessment, early treatment and follow-up assessments are important.

A 15-year experience with primary breast augmentation

BACKGROUND

This study evaluated patients who underwent primary breast surgery within a single group practice from 1994 to 2009. Reoperations were divided by reoperation reason into total reoperations and implant-specific reoperations. The authors hypothesized that the implant-specific reoperation rate will provide the most accurate measurement of complications caused by the breast implant device.

METHODS

A total of 812 patients received the same brand of breast implant for primary breast augmentation or augmentation/mastopexy. Safety and efficacy data were recorded and complication rates were calculated. Statistics were applied using Kaplan-Meier estimated cumulative incidence calculations.

RESULTS

This study included 482 patients with saline and 330 patients with silicone implants. The most common complications included capsular contracture, rippling, rupture, infection, and hematoma. A total of 8.2 percent of patients developed Baker grade III/IV capsular contracture by 6 years. The raw incidence of rippling was 7.1 percent, and the rate was significantly increased in underweight patients with subglandular saline implants (p = 0.045). The rate of total reoperation at 1 year was 14.2 percent. While a significantly increased rate of total reoperation was seen for silicone compared with saline implants (p < 0.01), no difference was seen in the rate of implant-specific reoperation for saline compared to silicone implants (p = 0.582).

CONCLUSIONS

The use of total reoperation rates as an indication of complications of breast implants can lead to both an overestimation of implant-related complications and the inaccurate conclusion that silicone implants result in higher complication rates than saline implants. The implant-specific reoperation rate may provide a more accurate incidence of implant complications than the total reoperation rate, which includes reoperations for factors unrelated to the implant.

Four-year follow-up of guided self-change for bulimia nervosa

The aim of this follow-up study was to evaluate the longer-term effectiveness of guided self-care for bulimia nervosa. In the original trial, 62 patients with DSM-III-R bulimia nervosa were randomly assigned to: a) a self-care manual plus eight fortnightly sessions of cognitive behavioural therapy (guided self-change); or b) 16 weekly sessions of cognitive behavioural therapy (CBT). Twenty-eight of these patients (45% of the original cohort) were involved in this follow-up study based on personal interviews by experts and self-rated instruments; the majority of the others could not be traced, but their pre- and post-treatment variables were not different from those of the follow-up patients. After an average follow-up of 54.2 months (SD 5.8), significant improvements were achieved or maintained in both groups in terms of the main outcome measures: eating disorder symptoms based on expert ratings (Eating Disorder Examination sub-scores for overeating, vomiting, dietary restraint, and shape and weight concerns), self report (Bulimic Investigatory Test Edinburgh), and a global five-point severity scale. There was also an improvement in the subsidiary outcome variables: Beck's Depression Inventory, the Self-concept Questionnaire, and knowledge of nutrition, weight and shape. During the week before the follow-up examination, 66.7% of the patients in the guided self-change group and 61.5% of those in the CBT group had not binged, vomited or abused laxatives. Guided self-change incorporating a self-care manual is an approach that can be as effective as standard cognitive behavioural therapy in the long-term, and can reduce the amount of therapist contact required.

Epidemiology of prescriptions for neuroleptic drugs: tranquilizers rather than antipsychotics

BACKGROUND

The pharmacology of neuroleptics as well as epidemiological and clinical observations of prescriptions of these drugs give the impression that they are and can be used for indications other than schizophrenia to a considerable degree.

METHOD

We analyzed pharmacoepidemiological data on neuroleptic prescriptions in Germany. We used the following criteria: numbers of defined daily doses (DDDs) per annum, diagnoses for which they were prescribed, patient age, specialist medical training of the prescribing physician, and indicators that neuroleptics were used instead of other psychotropic drugs such as minor tranquilizers.

RESULTS

Only 14% of the prescriptions for neuroleptic drugs were for schizophrenic psychoses, 18% for other paranoid psychoses and 5% for affective disorders. 63% were prescribed for neurotic disorders, sleep disorders, or dementia. Almost half of the neuroleptic prescriptions were given for patients aged 65 years or over. Only 40% were prescribed by psychiatrists or neurologists. Throughout the period from 1986 to 1995, neuroleptic prescriptions increased steadily, which was paralleled by a decrease in the prescription rates for benzodiazepines.

CONCLUSIONS

Evaluation is urgently needed for those uses of neuroleptic drugs that, from a pharmacoepidemiological perspective, must be seen as their primary indication.

[Prevalence of eating disorders among students]

A sample of 507 social work students completed the Bulimic Investigatory Test Edinburgh (BITE). Simulating diagnoses according to DSM-IV criteria, we found three women suffering from bulimia nervosa (BN). This represents a total prevalence of 0.6%, 0.8% in women, and 0.9% in female probands up to the age of 30 years. In the same way, we identified one case of anorexia nervosa (AN), i.e. a total prevalence of 0.2%, 0.3% in women, and 0.3% in female probands up to the age of 30. Nineteen students also fulfilled DSM-IV research criteria for binge-eating disorder (BED), showing a total prevalence of 3.7%, 3.8% in women, 3.5% in men, and 4.3% in female probands up to the age of 30. Thus, BED is the most common eating disorder and also occurs in men. In light of the association between weight discontent and eating disorders, suggestions are made for the management of overweight patients and both normal and underweight clients with eating disorders.

Guided self-change for bulimia nervosa incorporating use of a self-care manual

OBJECTIVE

The aim of this study was to evaluate the effectiveness of guided self-change for bulimia nervosa.

METHOD

Sixty-two patients with DSM-III-R-defined bulimia nervosa were randomly assigned to 1) use of a self-care manual plus eight fortnightly sessions of cognitive behavior therapy (guided self-change) or 2) 16 sessions of weekly cognitive behavior therapy.

RESULTS

At the end of treatment and at follow-up an average of 43 weeks after the end of therapy, substantial improvements had been achieved in both groups on the main outcome measures: eating disorder symptoms according to experts' ratings (Eating Disorder Examination subscores on overeating, vomiting, dietary restraint, and shape and weight concerns), self-reports (Bulimic Investigatory Test Edinburgh), and a 5-point severity scale. Also, improvement was seen on the subsidiary outcome measures: the Beck Depression Inventory, the Self-Concept Questionnaire, and knowledge of nutrition, weight, and shape. At follow-up, 71% of the cognitive behavior therapy group had not binged or vomited during the week preceding. In the guided self-change group, 70% had not binged and 61% had not vomited during the week before follow-up.

CONCLUSIONS

Guided self-change incorporating use of a self-care manual offers an approach that can be as effective as standard cognitive behavior therapy in the long term and can considerably reduce the amount of therapist contact required.

[How effective and acceptable is a self-treatment manual with concomitant brief therapy in bulimia nervosa]

We compared 8 fortnightly sessions plus a self-care manual (guided self change, GSC) with 16 weekly individual sessions of cognitive behaviour therapy (CBT). There were 31 sufferers of DSM-III-R-bulimia nervosa (BN) in each group. Both treatments resulted in significant improvements regarding self and interviewer based measures of bulimia nervosa as well as depression, self-esteem, quality of life and knowledge about nutrition, weight and shape. There were no significant differences between therapies regarding drop-out rate, compliance with follow-up, and the number of patients receiving additional treatment. At none of the assessments was there a significant difference between GSC and CBT regarding severity of BN, Beck Depression Inventory-score, self-esteem, and quality of life. A significantly higher percentage of CBT-patients were abstinent from bingeing for at least one week at the end of treatment. Three months later, the GSC-group had caught up in this respect and knew more about nutition, weight and shape. Only the sum-scores on a BN self-rating scale were worse for GSC than CBT at the end of therapy and at follow-up. There were no significant differences between the two groups in general treatment satisfaction and judgement about the usefulness of the therapies. Thus, guided self change with a selfcare manual can save therapist time without impinging significantly on treatment satisfaction and effectiveness.

[Help with self-care]

Instructions for self-treatment, whether printed, presented via computer or by audiovisual means, are effective in the management of phobias, panic disorder, other anxieties, depression, bulimia nervosa, obesity, alcohol problems, nicotine abuse, myocardial infarction, AIDS, compliance problems and the counseling of patients' relatives. A lasting improvement has been shown for up to 7 years. The mechanisms of effective self-change are discussed.

Psychopathology and family functioning in mothers with epilepsy

In a prospective comparative study of children born to mothers with epilepsy and to healthy controls, maternal psychopathology, family functioning and the effects of maternal psychopathology and family functioning on child mental status were investigated. The instruments used were the Present State Examination (PSE), the Past History Schedule (PHS), a psychiatric interview for preschool children and a structured interview about family functioning. Interviewers were blind to the clinical status of the mother. The group of mothers with epilepsy differed from the control group only regarding a higher prevalence of minor psychopathology and in 1 of 4 areas of family functioning. There was no difference between mothers with epilepsy and the control group regarding major psychopathology, and almost no differences regarding family functioning. The effect of maternal psychopathology on child mental status was mediated by disturbed family functioning only in the epilepsy group.

Pharmacotherapy of psychiatric disorder in pregnancy and during breastfeeding: a review

The literature in most European languages was consulted for guidelines regarding the drug treatment of psychiatrically disturbed pregnant or lactating women. The available information allows only a few conclusions. Lithium exposure during the first trimester seems to increase the risk of congenital heart disease, especially Ebstein's anomaly. As there is still insufficient evidence to prove the safeness of other psychoactive drugs for the fetus, caution seems warranted here too. A causal link between pharmacotherapy of the mother-to-be and malformation of the baby is difficult to prove. But toxic and withdrawal symptoms in infants born to women treated regularly until shortly before confinement are well documented for most psychoactive drugs.

[Psychotropic drugs and pregnancy: a review (author's transl)]

A wide range of literature on the use of psychoactive drugs in pregnancy and breastfeeding is reviewed critically and systemically. The question of 'guidelines' for an adequate treatment of pregnant psychiatric patients cannot be answered in an unequivocal or reassuring way. First of all, it is our inconclusive knowledge of this subject which demands caution prior to prescribing. Only in second line, isolated evidence of possible but mostly unproven damage to unborn children by the use of individual psychotropic drugs should be taken into account.