Multicenter randomized controlled phase III clinical trial using TNFerade (TNF) with chemoradiation (CRT) in patients with locally advanced pancreatic cancer (LAPC): Interim analysis (IA) of overall survival (OS)

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Intro: Local control of LAPC with CRT has historically demonstrated survival benefit vs. RT alone. TNF is a nonreplicating adenovirus vector delivering human tumor necrosis factor (TNF-α). Results from a phase II study with TNF in LAPC indicated a possible survival advantage. To confirm these findings, a randomized, open-label, controlled Pancreatic Cancer Trial with TNF (PACT) study was developed. Methods: The TNF arm received a 5 wk treatment of qw intratumoral inj of 4x1011 PU TNF, cont. iv 5-FU and 50.4Gy radiation. The standard of care (SOC) arm received CRT alone. Both groups received adjuvant gemcitabine(G) with the option of erlotinib(E). An IA of OS (primary efficacy endpoint) was planned after the first third (92) of the expected 276 total death events (from a total patient n=330). Nonparametric logrank of OS was planned; in addition, a lognormal model was used to account for an evident separation of the survival curves after the median. Results: 185 pts were available for OS analysis (117-TNF+SOC and 68-SOC). Survival in the TNF+SOC group demonstrated a HR of 0.753 (CI [0.494 - 1.15]) relative to SOC. Best fit parametric lognormal analysis indicated a median survival of 11.1 mo with TNF+SOC and 8.7 mo with SOC; nonparametric methods indicated a MS of 9.9 mo for both arms, with a pronounced “late effect” (75th percentile 19.4 mo with TNF+SOC and 11.8 mo with SOC). Prognostic information (G and E use, stage, etc) indicated equivalent distribution between groups. Conclusions: HR results of the OS IA indicate an encouraging trend in favor of the TNF treated group. Parametric medians may better reflect the true HR than nonparametric methods since the latter do not reflect the shape of the OS distribution. A second IA is planned after 2/3 total events.

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Cholangiocarcinoma: advocate an aggressive operative approach with adjuvant chemotherapy

Cholangiocarcinoma presents many challenges. Prognosis is thought to be determined by conventional predictors of survival; margin status, pathologic criteria, stage, and comorbid disease. Ninety-four patients, 57 males and 37 females, underwent resections for cholangiocarcinoma between 1989 and 2000. Thirty-two patients (34%) had distal tumors, 10 had midduct lesions, and 52 had proximal/intrahepatic lesions. Thirty-four patients underwent pancreaticoduodenectomies, 23 bile duct resections alone, and 37 bile duct and concomitant hepatic resections. Tumor location did not influence mean survival (distal, 28 months +/- 23; midduct, 28 months +/- 21; and proximal, 31 months +/- 36). Operation undertaken did not alter survival (bile duct resection, 30 months +/- 37; pancreaticoduodenectomy, 27 months +/- 23; and concomitant bile duct/hepatic resection, 32 months +/- 32). TNM stage failed to predict survival: 5 stage I (29 months +/- 22), 12 stage II (41 months +/- 33), 12 stage III (33 months +/- 19), and 64 stage IV (27 months +/- 32). Tumor size did not influence survival: T1-2 (32 months +/- 33) versus T3-4 lesions (29 months +/- 25). Mean survival with negative margin (n = 67) was 34 months +/- 33, whereas microscopically positive (n = 13, 23.9 months +/- 25) or grossly positive (n = 14, 20.4 months +/- 20) margins were predictive of significantly shorter survival (P < 0.03). Adjuvant treatment (n = 41) was associated with significantly longer survival (40.5 months +/- 36) than those who received no further therapy (n = 53; 24 months +/- 24) (P = 0.05). TNM stage, tumor size, operation undertaken, and location were not associated with duration of survival after resection. Margin status was associated with duration of survival, though extended survival is possible even with positive margins. Advanced stage should not preclude aggressive resection. Without specific contraindications, an aggressive operative approach is advocated followed by adjuvant therapy.

Cholangiocarcinoma: Advocate an Aggressive Operative Approach with Adjuvant Chemotherapy

Cholangiocarcinoma presents many challenges. Prognosis is thought to be determined by conventional predictors of survival; margin status, pathologic criteria, stage, and comorbid disease. Ninety-four patients, 57 males and 37 females, underwent resections for cholangiocarcinoma between 1989 and 2000. Thirty-two patients (34%) had distal tumors, 10 had midduct lesions, and 52 had proximal/intrahepatic lesions. Thirty-four patients underwent pancreaticoduodenectomies, 23 bile duct resections alone, and 37 bile duct and concomitant hepatic resections. Tumor location did not influence mean survival (distal, 28 months ± 23; midduct, 28 months ± 21; and proximal, 31 months ± 36). Operation undertaken did not alter survival (bile duct resection, 30 months ± 37; pancreaticoduodenectomy, 27 months ± 23; and concomitant bile duct/hepatic resection, 32 months ± 32). TNM stage failed to predict survival: 5 stage I (29 months ± 22), 12 stage II (41 months ± 33), 12 stage HI (33 months ± 19), and 64 stage IV (27 months ± 32). Tumor size did not influence survival: T1–2 (32 months ± 33) versus T3–4 lesions (29 months ± 25). Mean survival with negative margin (n = 67) was 34 months ± 33, whereas microscopically positive (n = 13, 23.9 months ± 25) or grossly positive (n = 14, 20.4 months ± 20) margins were predictive of significantly shorter survival ( P < 0.03). Adjuvant treatment (n = 41) was associated with significantly longer survival (40.5 months ± 36) than those who received no further therapy (n = 53; 24 months ± 24) ( P = 0.05). TNM stage, tumor size, operation undertaken, and location were not associated with duration of survival after resection. Margin status was associated with duration of survival, though extended survival is possible even with positive margins. Advanced stage should not preclude aggressive resection. Without specific contraindications, an aggressive operative approach is advocated followed by adjuvant therapy.

Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum

BACKGROUND

We evaluated outcome after laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication.

METHODS

Patients with symptomatic achalasia and epiphrenic diverticula underwent laparoscopic diverticulectomy, Heller myotomy, and partial fundoplication. Intraoperative endoscopy and postoperative esophagography were performed in all patients. Patients graded preoperative and postoperative dysphagia and heartburn on a Likert scale.

RESULTS

Anterior fundoplication was performed in five patients and posterior fundoplication in one. Mean follow-up was 9 months (range, 1-17 months). One intraoperative complication occurred--an esophagotomy that was laparoscopically repaired. There were no postoperative leaks. Patient-reported dysphagia decreased from 4.5 +/- 0.8 (mean +/- SD) to 1.8 +/- 1.7 ( p < 0.05 matched pair analysis). Heartburn decreased from 4.3 +/- 0.8 to 1.3 +/- 1.3 ( p < 0.05). All patients reported improvement in symptoms after operation.

CONCLUSION

Laparoscopic esophageal diverticulectomy, Heller myotomy, and partial fundoplication with intraoperative endoscopy safely reduce dysphagia associated with achalasia and esophageal diverticula while limiting symptoms of gastroesophageal reflux.

Laparoscopic revision of failed antireflux operations

BACKGROUND

A small number of patients fail fundoplication and require reoperation. Laparoscopic techniques have been applied to reoperative fundoplications. We reviewed our experience with reoperative laparoscopic fundoplication.

METHODS

Reoperative laparoscopic fundoplication was undertaken in 28 patients, 19 F and 9 M, of mean age 56 years +/- 12. Previous antireflux procedures included 19 open and 12 laparoscopic antireflux operations.

RESULTS

Symptoms were heartburn (90%), dysphagia (35%), and atypical symptoms (30%%). The mean interval from antireflux procedure to revision was 13 months +/- 4.2. The mean DeMeester score was 78+/-32 (normal 14.7). Eighteen patients (64%) had hiatal breakdown, 17 (60%) had wrap failure, 2 (7%) had slipped Nissen, 3 (11%) had paraesophageal hernias, and 1 (3%) had an excessively tight wrap. Twenty-five revisions were completed laparoscopically, while 3 patients required conversion to the open technique. Complications occurred in 9 of 17 (53%) patients failing previous open fundoplications and in 4 of 12 patients (33%) failing previous laparoscopic fundoplications and included 15 gastrotomies and 1 esophagotomy, all repaired laparoscopically, 3 postoperative gastric leaks, and 4 pneumothoraces requiring tube thoracostomy. No deaths occurred. Median length of stay was 5 days (range 2-90 days). At a mean follow-up of 20 months +/- 17, 2 patients (7%) have failed revision of their fundoplications, with the rest of the patients being essentially asymptomatic (93%).

CONCLUSIONS

The results achieved with reoperative laparoscopic fundoplication are similar to those of primary laparoscopic fundoplications. Laparoscopic reoperations, particularly of primary open fundoplication, can be technically challenging and fraught with complications.

Quality of life and antireflux medication use following laparoscopic Nissen fundoplication

With the advent of minimally invasive techniques, the surgical treatment of gastroesophageal reflux disease has received renewed interest. The efficacy of laparoscopic Nissen fundoplication in eliminating reflux has been documented. This study was undertaken to determine changes in quality of life and cost of antireflux medications after laparoscopic Nissen fundoplication. One hundred patients undergoing laparoscopic Nissen fundoplication between 1992 and 1997 completed questionnaires assessing changes in pre- and postoperative cost and number of antireflux medications, reflux symptoms, and quality of life. The average number of antireflux medications was significantly reduced (1.8 versus 0.3, P < 0.0001) as was the average monthly cost ($170 versus $30, P < 0.0001). Patients reported significant (P < 0.05) symptomatic improvement in postprandial heartburn, nocturnal heartburn, postprandial nausea, postprandial vomiting, dysphagia, and gas/bloating. Patients in this series noted fewer symptoms and used fewer antireflux medications at less cost after laparoscopic Nissen fundoplication. Symptoms commonly thought of as complications of fundoplication (vomiting, dysphagia, gas/bloating) were less common after fundoplication. This report documents the efficacy of laparoscopic fundoplication in improving quality of life and reducing use and cost of antireflux medications.

Impact of Bariatric Surgery on Body Image Perception and Sexuality in Morbidly Obese Patients and their Partners

BACKGROUND: This study was undertaken to determine whether surgery for morbid obesity affects sexual attitudes and performance in patients and their partners. METHODS: Questionnaires concerning sexuality were sent to 94 patients who underwent gastric restriction procedures and their partners. Twenty-eight patients at least 1 year postoperatively (range of 1-11 years, mean 4.2 years +/- 3.24 SD) and 16 of their partners responded. The blinded questionnaires addressed the enjoyment and frequency of sexual intercourse, orgasms, body image, number of partners, abuse, sexual problems and masturbation. Comparisons were made before and after surgery. Patient answers were compared with their partners. RESULTS: Preoperatively, 64% of patients stated that they enjoyed sexual intercourse. Postoperatively, 50% of patients and 78% of partners stated that they enjoyed sex more. Improved orgasms were noted by 44% of patients and 40% partners after surgery. Improvement in body image was also achieved. Only 27% of patients felt they were attractive before surgery, while 80% felt they were more attractive after surgery; 94% of their partners agreed. While 48% of patients undressed in darkness in front of their partners before surgery, only 27% did so after surgery. CONCLUSIONS: Weigh loss attained though bariatric surgery improves body image and sexuality. Sexual intercourse and orgasms are improved postoperatively both for patient and partner.