1
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Seelen LWF, Doppenberg D, Stoop TF, Nagelhout A, Brada LJH, Bosscha K, Busch OR, Cirkel GA, den Dulk M, Daams F, van Dieren S, van Eijck CHJ, Festen S, Groot Koerkamp B, Haj Mohammad N, de Hingh IHJT, Lips DJ, Los M, de Meijer VE, Patijn GA, Polée MB, Stommel MWJ, Walma MS, de Wilde RF, Wilmink JW, Molenaar IQ, van Santvoort HC, Besselink MG. Minimum and Optimal CA19-9 Response After Two Months Induction Chemotherapy in Patients With Locally Advanced Pancreatic Cancer: A Nationwide Multicenter Study. Ann Surg 2024; 279:832-841. [PMID: 37477009 DOI: 10.1097/sla.0000000000006021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE This nationwide multicenter study aimed to define clinically relevant thresholds of relative serum CA19-9 response after 2 months of induction chemotherapy in patients with locally advanced pancreatic cancer (LAPC). BACKGROUND CA19-9 is seen as leading biomarker for response evaluation in patients with LAPC, but early clinically useful cut-offs are lacking. METHODS All consecutive patients with LAPC after 4 cycles (m)FOLFIRINOX or 2 cycles gemcitabine-nab-paclitaxel induction chemotherapy (±radiotherapy) with CA19-9 ≥5 U/mL at baseline were analyzed (2015-2019). The association of CA19-9 response with median OS (mOS) was evaluated for different CA19-9 cut-off points. Minimum and optimal CA19-9 response were established via log-rank test. Predictors for OS were analyzed using COX regression analysis. RESULTS Overall, 212 patients were included, of whom 42 (19.8%) underwent resection. Minimum CA19-9 response demonstrating a clinically significant median OS difference (12.7 vs. 19.6 months) was seen at ≥40% CA19-9 decrease. The optimal cutoff for CA19-9 response was ≥60% decrease (21.7 vs. 14.0 mo, P =0.021). Only for patients with elevated CA19-9 levels at baseline (n=184), CA19-9 decrease ≥60% [hazard ratio (HR)=0.59, 95% CI, 0.36-0.98, P =0.042] was independently associated with prolonged OS, as were SBRT (HR=0.42, 95% CI, 0.25-0.70; P =0.001), and resection (HR=0.25, 95% CI, 0.14-0.46, P <0.001), and duration of chemotherapy (HR=0.75, 95% CI, 0.69-0.82, P <0.001). CONCLUSIONS CA19-9 decrease of ≥60% following induction chemotherapy as optimal response cut-off in patients with LAPC is an independent predictor for OS when CA19-9 is increased at baseline. Furthermore, ≥40% is the minimum cut-off demonstrating survival benefit. These cut-offs may be used when discussing treatment strategies during early response evaluation.
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Affiliation(s)
- Leonard W F Seelen
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Deesje Doppenberg
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Thomas F Stoop
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anne Nagelhout
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Lilly J H Brada
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Meander Medical Center Amersfoort, University Medical Center, Utrecht, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
| | - Freek Daams
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center, Utrecht, The Netherlands
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center, Utrecht, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Marco B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke S Walma
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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2
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Emmen AMLH, Zwart MJW, Khatkov IE, Boggi U, Groot Koerkamp B, Busch OR, Saint-Marc O, Dokmak S, Molenaar IQ, D'Hondt M, Ramera M, Keck T, Ferrari G, Luyer MDP, Moraldi L, Ielpo B, Wittel U, Souche FR, Hackert T, Lips D, Can MF, Bosscha K, Fara R, Festen S, van Dieren S, Coratti A, De Hingh I, Mazzola M, Wellner U, De Meyere C, van Santvoort HC, Aussilhou B, Ibenkhayat A, de Wilde RF, Kauffmann EF, Tyutyunnik P, Besselink MG, Abu Hilal M. Robot-assisted versus laparoscopic pancreatoduodenectomy: a pan-European multicenter propensity-matched study. Surgery 2024:S0039-6060(24)00078-3. [PMID: 38570225 DOI: 10.1016/j.surg.2024.02.015] [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] [Received: 08/30/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort. METHODS An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III). RESULTS Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001). CONCLUSION This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.
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Affiliation(s)
- Anouk M L H Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/AnoukEmmen
| | - Maurice J W Zwart
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/mauricezwart
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Russia
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Service de Chirurgie Digestive, Endocrinienne et Thoracique, Center Hospitalier Universitaire Orleans, France
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France. University Paris Cité
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, the Netherlands
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Belgium
| | - Marco Ramera
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Tobias Keck
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Germany
| | - Giovanni Ferrari
- Department of Oncological and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Luca Moraldi
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Benedetto Ielpo
- Department of Surgery, HPB unit, University Mar Hospital, Parc Salut, Barcelona, Spain
| | - Uwe Wittel
- Department of Surgery, University of Freiburg, Germany
| | - Francois-Regis Souche
- Department de Chirurgie Digestive (A), Mini-invasive et Oncologigue, Hôspital Saint-Eloi, Montpellier, France
| | - Thilo Hackert
- Dept. of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, s-Hertogenbosch, the Netherlands
| | - Regis Fara
- Department of Surgery, Hôpital Européen Marseille, France
| | | | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Andrea Coratti
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Ignace De Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Michele Mazzola
- Department of Oncological and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ulrich Wellner
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Germany
| | - Celine De Meyere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital Kortrijk, Belgium
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, the Netherlands
| | - Béatrice Aussilhou
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France. University Paris Cité
| | - Abdallah Ibenkhayat
- Service de Chirurgie Digestive, Endocrinienne et Thoracique, Center Hospitalier Universitaire Orleans, France
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Pavel Tyutyunnik
- Department of Surgery, Moscow Clinical Scientific Center, Russia
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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3
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Stoop TF, Seelen LWF, Van't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, Dulk MD, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Riele WT, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. ASO Visual Abstract: Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2662-2663. [PMID: 38253952 DOI: 10.1245/s10434-023-14790-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St, Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Freek R Van't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St, Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St, Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St, Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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4
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Davis CH, Augustinus S, de Graaf N, Wellner UF, Johansen K, Andersson B, Beane JD, Björnsson B, Busch OR, Gleeson EM, van Santvoort HC, Tingstedt B, Williamsson C, Keck T, Besselink MG, Koerkamp BG, Pitt HA. Impact of Neoadjuvant Therapy for Pancreatic Cancer: Transatlantic Trend and Postoperative Outcomes Analysis. J Am Coll Surg 2024; 238:613-621. [PMID: 38224148 DOI: 10.1097/xcs.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND The introduction of modern chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). A recent North American study demonstrated increased use of NAT and improved operative outcomes in patients with PDAC. The aims of this study were to compare the use of NAT and short-term outcomes in patients with PDAC undergoing pancreatoduodenectomy (PD) among registries from the US and Canada, Germany, the Netherlands, and Sweden. STUDY DESIGN Databases from 2 multicenter (voluntary) and 2 nationwide (mandatory) registries were queried from 2018 to 2020. Patients undergoing PD for PDAC were compared based on the use of upfront surgery vs NAT. Adoption of NAT was measured in each country over time. Thirty-day outcomes, including the composite measure (ideal outcomes), were compared by multivariable analyses. Sensitivity analyses of patients undergoing vascular resection were performed. RESULTS Overall, 11,402 patients underwent PD for PDAC with 33.7% of patients receiving NAT. The use of NAT increased steadily from 28.3% in 2018 to 38.5% in 2020 (p < 0.0001). However, use of NAT varied widely by country: the US (46.8%), the Netherlands (44.9%), Sweden (11.0%), and Germany (7.8%). On multivariable analysis, NAT was significantly (p < 0.01) associated with reduced rates of serious morbidity, clinically relevant pancreatic fistulae, reoperations, and increased ideal outcomes. These associations remained on sensitivity analysis of patients undergoing vascular resection. CONCLUSIONS NAT before PD for pancreatic cancer varied widely among 4 Western audits yet increased by 26% during 3 years. NAT was associated with improved short-term outcomes.
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Affiliation(s)
- Catherine H Davis
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands (Augustinus, de Graaf, Busch, Besselink)
| | - Ulrich F Wellner
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Karin Johansen
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Bodil Andersson
- Departments of Surgery and Clinical Sciences Lund, Lund University, Lund, Sweden (Andersson)
- Skåne University Hospital, Lund, Sweden (Andersson)
| | - Joal D Beane
- Department of Surgery, The Ohio State University, Columbus, OH (Beane)
| | - Bergthor Björnsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Olivier R Busch
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Elizabeth M Gleeson
- Department of Surgery, University of North Carolina, Chapel Hill, NC (Gleeson)
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands (van Santvoort)
| | - Bobby Tingstedt
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Caroline Williamsson
- Departments of Surgery and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden (Johansen, Björnsson, Tingstedt, Williamsson)
| | - Tobias Keck
- DGAV StuDoQ/Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany (Wellner, Keck)
| | - Marc G Besselink
- From the Department of Surgery, Baylor Scott & White Health, Dallas, TX (Davis)
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands (Koerkamp)
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (Pitt)
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5
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Mackay TM, Latenstein AEJ, Augustinus S, van der Geest LG, Bogte A, Bonsing BA, Cirkel GA, Hol L, Busch OR, den Dulk M, van Driel LMJ, Festen S, de Groot DJA, de Groot JWB, Groot Koerkamp B, Haj Mohammad N, Haver JT, van der Harst E, de Hingh IH, Homs MYV, Los M, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, Patijn GA, Quispel R, Römkens TEH, van Santvoort HC, Stommel MW, Venneman NG, Verdonk RC, van Vilsteren FGI, de Vos-Geelen J, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Implementation of Best Practices in Pancreatic Cancer Care in the Netherlands: A Stepped-Wedge Randomized Clinical Trial. JAMA Surg 2024; 159:429-437. [PMID: 38353966 PMCID: PMC10867778 DOI: 10.1001/jamasurg.2023.7872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/26/2023] [Indexed: 02/17/2024]
Abstract
Importance Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal. Objective To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival. Design, setting, and participants This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients). Intervention The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care. Main Outcomes and Measures The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score). Results Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, -1.09, 95% CI, -3.05 to 0.94). Conclusions and Relevance In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options. Trial Registration ClinicalTrials.gov Identifier: NCT03513705.
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Affiliation(s)
- Tara M. Mackay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Anouk E. J. Latenstein
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Simone Augustinus
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Lydia G. van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
- NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany, the Netherlands
| | | | | | | | | | | | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | - Joyce T. Haver
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of nutrition and dietetics, Amsterdam, the Netherlands
| | | | | | | | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands
| | - Leonie Mekenkamp
- Department of Medical Oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Rutger Quispel
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Tessa E. H. Römkens
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Niels G. Venneman
- Department of Gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Judith de Vos-Geelen
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Johanna W. Wilmink
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, the Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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6
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Stoop TF, Seelen LWF, van 't Land FR, Lutchman KRD, van Dieren S, Lips DJ, van der Harst E, Kazemier G, Patijn GA, de Hingh IH, Wijsman JH, Erdmann JI, Festen S, Groot Koerkamp B, Mieog JSD, den Dulk M, Stommel MWJ, Busch OR, de Wilde RF, de Meijer VE, Te Riele W, Molenaar IQ, van Eijck CHJ, van Santvoort HC, Besselink MG. Nationwide Use and Outcome of Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy. Ann Surg Oncol 2024; 31:2640-2653. [PMID: 38105377 DOI: 10.1245/s10434-023-14650-6] [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: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Several international high-volume centers have reported good outcomes after resection of locally advanced pancreatic cancer (LAPC) following chemo(radio)therapy, but it is unclear how this translates to nationwide clinical practice and outcome. This study aims to assess the nationwide use and outcome of resection of LAPC following induction chemo(radio)therapy. PATIENTS AND METHODS A multicenter retrospective study including all patients who underwent resection for LAPC following chemo(radio)therapy in all 16 Dutch pancreatic surgery centers (2014-2020), registered in the mandatory Dutch Pancreatic Cancer Audit. LAPC is defined as arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion. RESULTS Overall, 142 patients underwent resection for LAPC, of whom 34.5% met the 2022 National Comprehensive Cancer Network criteria. FOLFIRINOX was the most commonly (93.7%) used chemotherapy [median 5 cycles (IQR 4-8)]. Venous and arterial resections were performed in 51.4% and 14.8% of patients. Most resections (73.9%) were performed in high-volume centers (i.e., ≥ 60 pancreatoduodenectomies/year). Overall median volume of LAPC resections/center was 4 (IQR 1-7). In-hospital/30-day major morbidity was 37.3% and 90-day mortality was 4.2%. Median OS from diagnosis was 26 months (95% CI 23-28) and 5-year OS 18%. Surgery in high-volume centers [HR = 0.542 (95% CI 0.318-0.923)], ypN1-2 [HR = 3.141 (95% CI 1.886-5.234)], and major morbidity [HR = 2.031 (95% CI 1.272-3.244)] were associated with OS. CONCLUSIONS Resection of LAPC following chemo(radio)therapy is infrequently performed in the Netherlands, albeit with acceptable morbidity, mortality, and OS. Given these findings, a structured nationwide approach involving international centers of excellence would be needed to improve selection of patients with LAPC for surgical resection following induction therapy.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Freek R van 't Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Kishan R D Lutchman
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location Vrije University, Department of Surgery, Amsterdam, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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7
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Overdevest AG, Fritzsche JA, Smit MAD, Besselink MG, Bonomi AM, Busch OR, Daams F, van Delden OM, Kazemier G, Langver J, Ponsioen CY, Swijnenburg RJ, van Wanrooij RLJ, Wielenga MCB, Zonderhuis BM, Zijlstra IJAJ, Erdmann JI, Voermans RP. Recurrent cholangitis in patients with a non-stenotic hepaticojejunostomy: incidence and risk factors. HPB (Oxford) 2024; 26:558-564. [PMID: 38245491 DOI: 10.1016/j.hpb.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/27/2023] [Accepted: 01/05/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Cholangitis is a well-known complication after hepaticojejunostomy (HJ), which is mainly caused by a stenotic anastomosis. However, the rate of cholangitis in patients with a non-stenotic (i.e. patent) HJ is unknown. We aimed to evaluate the incidence and risk factors of recurrent cholangitis in patients with a non-stenotic HJ. METHODS This single-center retrospective cohort study included all consecutive patients who had undergone hepatobiliary or pancreatic (HPB) surgery requiring HJ (2015-2022). Primary outcome was recurrent non-stenotic cholangitis, risk factors for recurrent non-stenotic cholangitis were identified using logistic regression. RESULTS Overall, 835 patients with a HJ were included of whom 31/698 (4.4%) patients developed recurrent cholangitis with a non-stenotic HJ during a median follow-up of 34 months (IQR 22-50) and 98/796 (12.3%) patients developed a symptomatic HJ stenosis. These 31 patients experienced 205 cholangitis episodes, median 7.0 (IQR 3.8-8.8) per patient, and 71/205 (34.6%) cholangitis episodes required hospitalization. Male sex (aOR 3.17 (95% CI: 1.34-7.49)) and benign disease (aOR 2.97, 95% CI 1.40-6.33) were identified as risk factors for recurrent cholangitis in non-stenotic HJ in both univariate and multivariable analysis. CONCLUSION This study shows that 4% of patients developed recurrent cholangitis without an underlying HJ stenosis.
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Affiliation(s)
- Anouk G Overdevest
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands.
| | - Jeska A Fritzsche
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Mark A D Smit
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | | | - Olivier R Busch
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Freek Daams
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Otto M van Delden
- Amsterdam UMC, Location University of Amsterdam, Department of (Interventional) Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Jesse Langver
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - Cyriel Y Ponsioen
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Rutger-Jan Swijnenburg
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Roy L J van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands
| | - Mattheus C B Wielenga
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - IJsbrand A J Zijlstra
- Amsterdam UMC, Location University of Amsterdam, Department of (Interventional) Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - Joris I Erdmann
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands.
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8
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van Bodegraven EA, van Ramshorst TME, Bratlie SO, Kokkola A, Sparrelid E, Björnsson B, Kleive D, Burgdorf SK, Dokmak S, Groot Koerkamp B, Cabús SS, Molenaar IQ, Boggi U, Busch OR, Petrič M, Roeyen G, Hackert T, Lips DJ, D'Hondt M, Coolsen MME, Ferrari G, Tingstedt B, Serrablo A, Gaujoux S, Ramera M, Khatkov I, Ausania F, Souche R, Festen S, Berrevoet F, Keck T, Sutcliffe RP, Pando E, de Wilde RF, Aussilhou B, Krohn PS, Edwin B, Sandström P, Gilg S, Seppänen H, Vilhav C, Abu Hilal M, Besselink MG. Minimally invasive robot-assisted and laparoscopic distal pancreatectomy in a pan-European registry a retrospective cohort study. Int J Surg 2024:01279778-990000000-01209. [PMID: 38498397 DOI: 10.1097/js9.0000000000001315] [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] [Received: 12/11/2023] [Accepted: 02/26/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND International guidelines recommend monitoring of the use and outcome of minimally invasive pancreatic surgery (MIPS). However, data from prospective international audits on minimally invasive distal pancreatectomy (MIDP) are lacking. This study examined the use and outcome of robot-assisted (RDP) and laparoscopic (LDP) distal pancreatectomy in the E-MIPS registry. MATERIALS AND METHODS Post-hoc analysis in a prospective audit on MIPS, including consecutive patients undergoing MIDP in 83 centers from 19 European countries (01-01-2019/31-12-2021). Primary outcomes included intraoperative events (grade 1: excessive blood loss, grade 2: conversion/change in operation, grade 3: intraoperative death), major morbidity, and in-hospital/30-day mortality. Multivariable logistic regression analyses identified high-risk groups for intraoperative events. RDP and LDP were compared in the total cohort and in high-risk groups. RESULTS Overall, 1672 patients undergoing MIDP were included; 606 (36.2%) RDP and 1066 (63.8%) LDP. The annual use of RDP increased from 30.5% to 42.6% (P<0.001). RDP was associated with fewer grade 2 intraoperative events compared to LDP (9.6% vs. 16.8%, P<0.001), with longer operating time (238 vs. 201 minutes,P<0.001). No significant differences were observed between RDP and LDP regarding major morbidity (23.4% vs. 25.9%, P=0.264) and in-hospital/30-day mortality (0.3% vs. 0.8%, P=0.344). Three high-risk groups were identified; BMI>25 kg/m2, previous abdominal surgery, and vascular involvement. In each group, RDP was associated with fewer conversions and longer operative times. CONCLUSION This European registry-based study demonstrated favorable outcomes for MIDP, with mortality rates below 1%. LDP remains the predominant approach, whereas the use of RDP is increasing. RDP was associated with less conversions and longer operative time, including in high-risk subgroups. Future randomized trials should confirm these findings and assess cost differences.
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Affiliation(s)
- Eduard A van Bodegraven
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Tess M E van Ramshorst
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Svein O Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Dyre Kleive
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Stefan K Burgdorf
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Safi Dokmak
- Departement of HPB surgery and liver transplantation, APHP Beaujon Hospital - University of Paris Cité, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, UMC Utrecht Cancer Centre and St Antonius Hospital Nieuwegein, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ugo Boggi
- Division of General and Transplant surgery, University of Pisa, Pisa, Italy
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Miha Petrič
- Department of Abdominal Surgery, Ljubljana University Medical Center, Zaloška cesta 7, 1000, Ljubljana, Slovenia
| | - Geert Roeyen
- Department of HPB, Endocrine and Transplantation Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium and University of Antwerp, Wilrijk, Belgium
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherland
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht University Medical Center+ , University of Maastricht , Maastricht, the Netherlands
| | - Giovanni Ferrari
- Division of Minimally Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza, Spain
| | - Sebastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, FRANCE
| | - Marco Ramera
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Fabio Ausania
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Regis Souche
- Department of Surgery, Saint-Éloi Hospital, Montpellier, France
| | | | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Pando
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Beatrice Aussilhou
- Departement of HPB surgery and liver transplantation, APHP Beaujon Hospital - University of Paris Cité, Clichy, France
| | - Paul S Krohn
- Department of Surgery and Transplantation, Rigshospitalet Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Per Sandström
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Seppänen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Caroline Vilhav
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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9
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Boeckxstaens G, Elsen S, Belmans A, Annese V, Bredenoord AJ, Busch OR, Costantini M, Fumagalli U, Smout AJPM, Tack J, Vanuytsel T, Zaninotto G, Salvador R. 10-year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy. Gut 2024; 73:582-589. [PMID: 38050085 DOI: 10.1136/gutjnl-2023-331374] [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: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE As achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia Trial comparing endoscopic pneumodilation (PD) with laparoscopic Heller myotomy (LHM). DESIGN A total of 201 newly diagnosed patients with achalasia were randomised to either a series of PDs (n=96) or LHM (n=105). Patients completed symptom (Eckardt score) and quality-of-life questionnaires, underwent functional tests and upper endoscopy. Primary outcome was therapeutic success defined as Eckardt score <3 at yearly follow-up. Secondary outcomes were the need for retreatment, lower oesophageal sphincter pressure, oesophageal emptying, gastro-oesophageal reflux and the rate of complications. RESULTS After 10 years of follow-up, LHM (n=40) and PD (n=36) were equally effective in both the full analysis set (74% vs 74%, p=0.84) and the per protocol set (74% vs 86%, respectively, p=0.07). Subgroup analysis revealed that PD was superior to LHM for type 2 achalasia (p=0.03) while there was a trend, although not significant (p=0.05), that LHM performed better for type 3 achalasia. Barium column height after 5 min at timed barium oesophagram was significantly higher for patients treated with PD compared with LHM, while other parameters, including gastro-oesophageal reflux, were not different. CONCLUSIONS PD and LHM are equally effective even after 10 years of follow-up with limited risk to develop gastro-oesophageal reflux. Based on these data, we conclude that PD and LHM can both be proposed as initial treatment of achalasia.
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Affiliation(s)
- Guy Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Stefanie Elsen
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium
| | - Vito Annese
- Department of Gastroenterology, IRCCS San Donato Policlinic, San Donato Milanese, Vita-Salute San Raffaele University, Milano, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
| | - Uberto Fumagalli
- Department of Digestive Surgery, European Institute of Oncology - IRCCS, Milano, Italy
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
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10
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Wismans LV, Suurmeijer JA, van Dongen JC, Bonsing BA, Van Santvoort HC, Wilmink JW, van Tienhoven G, de Hingh IH, Lips DJ, van der Harst E, de Meijer VE, Patijn GA, Bosscha K, Stommel MW, Festen S, den Dulk M, Nuyttens JJ, Intven MPW, de Vos-Geelen J, Molenaar IQ, Busch OR, Koerkamp BG, Besselink MG, van Eijck CHJ. Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis. Surgery 2024:S0039-6060(24)00055-2. [PMID: 38448277 DOI: 10.1016/j.surg.2024.01.029] [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] [Received: 06/29/2023] [Revised: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. METHODS All patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014-2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. RESULTS Overall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03-0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25-1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). CONCLUSION This nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.
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Affiliation(s)
- Leonoor V Wismans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, the Netherlands; Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/MarcBesselink
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
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11
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Schouten TJ, van Goor IWJM, Dorland GA, Besselink MG, Bonsing BA, Bosscha K, Brosens LAA, Busch OR, Cirkel GA, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Intven MPW, Kazemier G, Liem MSL, van Lienden KP, Los M, de Meijer VE, Patijn GA, Schreinemakers JMJ, Stommel MWJ, van Tienhoven GJ, Verdonk RC, Verkooijen HM, van Santvoort HC, Molenaar IQ, Daamen LA. The Value of Biological and Conditional Factors for Staging of Patients with Resectable Pancreatic Cancer Undergoing Upfront Resection: A Nationwide Analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15070-w. [PMID: 38386198 DOI: 10.1245/s10434-024-15070-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Novel definitions suggest that resectability status for pancreatic ductal adenocarcinoma (PDAC) should be assessed beyond anatomical criteria, considering both biological and conditional factors. This has, however, yet to be validated on a nationwide scale. This study evaluated the prognostic value of biological and conditional factors for staging of patients with resectable PDAC. PATIENTS AND METHODS A nationwide observational cohort study was performed, including all consecutive patients who underwent upfront resection of National Comprehensive Cancer Network resectable PDAC in the Netherlands (2014-2019) with complete information on preoperative carbohydrate antigen (CA) 19-9 and Eastern Cooperative Oncology Group (ECOG) performance status. PDAC was considered biologically unfavorable (RB+) if CA19-9 ≥ 500 U/mL and favorable (RB-) otherwise. ECOG ≥ 2 was considered conditionally unfavorable (RC+) and favorable otherwise (RC-). Overall survival (OS) was assessed using Kaplan-Meier and Cox-proportional hazard analysis, presented as hazard ratios (HRs) with 95% confidence interval (CI). RESULTS Overall, 688 patients were analyzed with a median overall survival (OS) of 20 months (95% CI 19-23). OS was 14 months (95% CI 10 months-median not reached) in 20 RB+C+ patients (3%; HR 1.61, 95% CI 0.86-2.70), 13 months (95% CI 11-15) in 156 RB+C- patients (23%; HR 1.86, 95% CI 1.50-2.31), and 21 months (95% CI 12-41) in 47 RB-C+ patients (7%; HR 1.14, 95% CI 0.80-1.62) compared with 24 months (95% CI 22-27) in 465 patients with RB-C- PDAC (68%; reference). CONCLUSIONS Survival after upfront resection of anatomically resectable PDAC is worse in patients with CA19-9 ≥ 500 U/mL, while performance status had no impact. This supports consideration of CA19-9 in preoperative staging of resectable PDAC.
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Affiliation(s)
- Thijs J Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Iris W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Galina A Dorland
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center 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
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geert A Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
- Department of Medical Oncology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+,, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ignace H J T de Hingh
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Krijn P van Lienden
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geert Jan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Radiation Oncology, location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands.
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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12
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Bereska JI, Janssen BV, Nio CY, Kop MPM, Kazemier G, Busch OR, Struik F, Marquering HA, Stoker J, Besselink MG, Verpalen IM. Artificial intelligence for assessment of vascular involvement and tumor resectability on CT in patients with pancreatic cancer. Eur Radiol Exp 2024; 8:18. [PMID: 38342782 PMCID: PMC10859357 DOI: 10.1186/s41747-023-00419-9] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/09/2023] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE This study aimed to develop and evaluate an automatic model using artificial intelligence (AI) for quantifying vascular involvement and classifying tumor resectability stage in patients with pancreatic ductal adenocarcinoma (PDAC), primarily to support radiologists in referral centers. Resectability of PDAC is determined by the degree of vascular involvement on computed tomography scans (CTs), which is associated with considerable inter-observer variability. METHODS We developed a semisupervised machine learning segmentation model to segment the PDAC and surrounding vasculature using 613 CTs of 467 patients with pancreatic tumors and 50 control patients. After segmenting the relevant structures, our model quantifies vascular involvement by measuring the degree of the vessel wall that is in contact with the tumor using AI-segmented CTs. Based on these measurements, the model classifies the resectability stage using the Dutch Pancreatic Cancer Group criteria as either resectable, borderline resectable, or locally advanced (LA). RESULTS We evaluated the performance of the model using a test set containing 60 CTs from 60 patients, consisting of 20 resectable, 20 borderline resectable, and 20 locally advanced cases, by comparing the automated analysis obtained from the model to expert visual vascular involvement assessments. The model concurred with the radiologists on 227/300 (76%) vessels for determining vascular involvement. The model's resectability classification agreed with the radiologists on 17/20 (85%) resectable, 16/20 (80%) for borderline resectable, and 15/20 (75%) for locally advanced cases. CONCLUSIONS This study demonstrates that an AI model may allow automatic quantification of vascular involvement and classification of resectability for PDAC. RELEVANCE STATEMENT This AI model enables automated vascular involvement quantification and resectability classification for pancreatic cancer, aiding radiologists in treatment decisions, and potentially improving patient outcomes. KEY POINTS • High inter-observer variability exists in determining vascular involvement and resectability for PDAC. • Artificial intelligence accurately quantifies vascular involvement and classifies resectability for PDAC. • Artificial intelligence can aid radiologists by automating vascular involvement and resectability assessments.
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Affiliation(s)
- Jacqueline I Bereska
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Boris V Janssen
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - C Yung Nio
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marnix P M Kop
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Femke Struik
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Inez M Verpalen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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13
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de Graaf N, Zwart MJW, van Hilst J, van den Broek B, Bonsing BA, Busch OR, Coene PPLO, Daams F, van Dieren S, van Eijck CHJ, Festen S, de Hingh IHJT, Lips DJ, Luyer MDP, Mieog JSD, van Santvoort HC, van der Schelling GP, Stommel MWJ, de Wilde RF, Molenaar IQ, Groot Koerkamp B, Besselink MG. Early experience with robotic pancreatoduodenectomy versus open pancreatoduodenectomy: nationwide propensity-score-matched analysis. Br J Surg 2024; 111:znae043. [PMID: 38415878 PMCID: PMC10898866 DOI: 10.1093/bjs/znae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Although robotic pancreatoduodenectomy has shown promising outcomes in experienced high-volume centres, it is unclear whether implementation on a nationwide scale is safe and beneficial. The aim of this study was to compare the outcomes of the early experience with robotic pancreatoduodenectomy versus open pancreatoduodenectomy in the Netherlands. METHODS This was a nationwide retrospective cohort study of all consecutive patients who underwent robotic pancreatoduodenectomy or open pancreatoduodenectomy who were registered in the mandatory Dutch Pancreatic Cancer Audit (18 centres, 2014-2021), starting from the first robotic pancreatoduodenectomy procedure per centre. The main endpoints were major complications (Clavien-Dindo grade greater than or equal to III) and in-hospital/30-day mortality. Propensity-score matching (1 : 1) was used to minimize selection bias. RESULTS Overall, 701 patients who underwent robotic pancreatoduodenectomy and 4447 patients who underwent open pancreatoduodenectomy were included. Among the eight centres that performed robotic pancreatoduodenectomy, the median robotic pancreatoduodenectomy experience was 86 (range 48-149), with a 7.3% conversion rate. After matching (698 robotic pancreatoduodenectomy patients versus 698 open pancreatoduodenectomy control patients), no significant differences were found in major complications (40.3% versus 36.2% respectively; P = 0.186), in-hospital/30-day mortality (4.0% versus 3.1% respectively; P = 0.326), and postoperative pancreatic fistula grade B/C (24.9% versus 23.5% respectively; P = 0.578). Robotic pancreatoduodenectomy was associated with a longer operating time (359 min versus 301 min; P < 0.001), less intraoperative blood loss (200 ml versus 500 ml; P < 0.001), fewer wound infections (7.4% versus 12.2%; P = 0.008), and a shorter hospital stay (11 days versus 12 days; P < 0.001). Centres performing greater than or equal to 20 robotic pancreatoduodenectomies annually had a lower mortality rate (2.9% versus 7.3%; P = 0.009) and a lower conversion rate (6.3% versus 11.2%; P = 0.032). CONCLUSION This study indicates that robotic pancreatoduodenectomy was safely implemented nationwide, without significant differences in major morbidity and mortality compared with matched open pancreatoduodenectomy patients. Randomized trials should be carried out to verify these findings and confirm the observed benefits of robotic pancreatoduodenectomy versus open pancreatoduodenectomy.
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Affiliation(s)
- Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
- Epidemiologist Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | | | | | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Martijn W J Stommel
- Deptartment of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Amsterdam, The Netherlands
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14
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Gorris M, van Bodegraven EA, Abu Hilal M, Bolm L, Busch OR, del Chiaro M, Habib J, Hasegawa K, He J, van Hooft JE, Jang JY, Javed AA, Kazami Y, Kwon W, Lee M, Liu R, Motoi F, Perri G, Saiura A, Salvia R, Sasanuma H, Takeda Y, Wolfgang C, Zelga P, del Castillo CF, Marchegiani G, Besselink MG. Outcomes after distal pancreatectomy with or without splenectomy for intraductal papillary mucinous neoplasm: international multicentre cohort study. Br J Surg 2024; 111:znad424. [PMID: 38195084 PMCID: PMC10776207 DOI: 10.1093/bjs/znad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/18/2023] [Accepted: 12/05/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND International guidelines on intraductal papillary mucinous neoplasm (IPMN) recommend a formal oncological resection including splenectomy when distal pancreatectomy is indicated. This study aimed to compare oncological and surgical outcomes after distal pancreatectomy with or without splenectomy in patients with presumed IPMN. METHODS An international, retrospective cohort study was undertaken in 14 high-volume centres from 7 countries including consecutive patients after distal pancreatectomy for IPMN (2005-2019). Patients were divided into spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). The primary outcome was lymph node metastasis (LNM). Secondary outcomes were overall survival, duration of operation, blood loss, and secondary splenectomy. RESULTS Overall, 700 patients were included after distal pancreatectomy for IPMN; 123 underwent SPDP (17.6%) and 577 DPS (82.4%). The rate of malignancy was 29.6% (137 patients) and the overall rate of LNM 6.7% (47 patients). Patients with preoperative suspicion of malignancy had a LNM rate of 17.2% (23 of 134) versus 4.3% (23 of 539) among patients without suspected malignancy (P < 0.001). Overall, SPDP was associated with a shorter operating time (median 180 versus 226 min; P = 0.001), less blood loss (100 versus 336 ml; P = 0.001), and shorter hospital stay (5 versus 8 days; P < 0.001). No significant difference in overall survival was observed between SPDP and DPS for IPMN after correction for prognostic factors (HR 0.50, 95% c.i. 0.22 to 1.18; P = 0.504). CONCLUSION This international cohort study found LNM in 6.7% of patients undergoing distal pancreatectomy for IPMN. In patients without preoperative suspicion of malignancy, SPDP seemed oncologically safe and was associated with improved short-term outcomes compared with DPS.
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Affiliation(s)
- Myrte Gorris
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of Hepatopancreatobiliary Surgery, University Hospital Southampton, Southampton, UK
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
| | - Louisa Bolm
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Marco del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joseph Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yusuke Kazami
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, First Medical Centre of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Fuyuhiko Motoi
- Department of Surgery I, Yamagata University, Yamagata, Japan
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Akio Saiura
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Hideki Sasanuma
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yoshinori Takeda
- Department of Hepatobiliary–Pancreatic Surgery, Juntendo University School of Medicine, Hongo, Tokyo, Japan
| | | | - Piotr Zelga
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
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15
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Overbeek KA, Koopmann BDM, Levink IJM, Tacelli M, Erler NS, Arcidiacono PG, Ausems MGE, Wagner A, van Eijck CH, Groot Koerkamp B, Busch OR, Besselink MG, van der Vlugt M, van Driel LMJW, Fockens P, Vleggaar FP, Poley JW, Capurso G, Cahen DL, Bruno MJ. Intraductal Papillary Mucinous Neoplasms in High-Risk Individuals: Incidence, Growth Rate, and Malignancy Risk. Clin Gastroenterol Hepatol 2024; 22:62-71.e7. [PMID: 37031711 DOI: 10.1016/j.cgh.2023.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/19/2023] [Accepted: 03/29/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND AND AIMS In high-risk individuals (HRIs), we aimed to assess the cumulative incidence of intraductal papillary mucinous neoplasms (IPMNs) and compare IPMN growth, neoplastic progression rate, and the value of growth as predictor for neoplastic progression to these in sporadic IPMNs. METHODS We performed annual surveillance of Dutch HRIs, involving carriers of germline pathogenic variants (PVs) and PV-negative familial pancreatic cancer kindreds. HRIs with IPMNs were compared with Italian individuals without familial risk under surveillance for sporadic IPMNs. RESULTS A total of 457 HRIs were followed for 48 (range 2-172) months; the estimated cumulative IPMN incidence was 46% (95% confidence interval, 28%-64%). In comparison with 442 control individuals, IPMNs in HRIs were more likely to grow ≥2.5 mm/y (31% vs 7%; P < .001) and develop worrisome features (32% vs 19%; P = .010). PV carriers with IPMNs more often displayed neoplastic progression (n = 3 [11%] vs n = 6 [1%]; P = .011), while familial pancreatic cancer kindreds did not (n = 0 [0%]; P = 1.000). The malignancy risk in a PV carrier with an IPMN was 23% for growth rates ≥2.5 mm/y (n = 13), 30% for ≥5 mm/y (n = 10), and 60% for ≥10 mm/y (n = 5). CONCLUSIONS The cumulative incidence of IPMNs in HRIs is higher than previously reported in the general population. Compared with sporadic IPMNs, they have an increased growth rate. PV carriers with IPMNs are suggested to be at a higher malignancy risk. Intensive follow-up should be considered for PV carriers with an IPMN growing ≥2.5 mm/y, and surgical resection for those growing ≥5 mm/y.
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Affiliation(s)
- Kasper A Overbeek
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Brechtje D M Koopmann
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Iris J M Levink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Matteo Tacelli
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margreet G E Ausems
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anja Wagner
- Department of Clinical Genetics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Manon van der Vlugt
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam Gastroenterology Endocrinology & Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam Gastroenterology Endocrinology & Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy; Digestive and Liver Disease Unit, Sant'Andrea Hospital, Rome, Italy
| | - Djuna L Cahen
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
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16
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Fritzsche JA, Fockens P, Besselink MG, Busch OR, Daams F, Montazeri NSM, Wilmink JW, Voermans RP, Van Wanrooij RLJ. Endoscopic ultrasound-guided choledochoduodenostomy using single-step lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-p): a prospective pilot study. Endoscopy 2024; 56:47-52. [PMID: 37473780 DOI: 10.1055/a-2134-3537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
BACKGROUND This study aimed to assess the safety and feasibility of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent (LAMS) as a primary drainage strategy in patients with distal malignant biliary obstruction (MBO). METHODS A prospective, single-center, pilot study was conducted in patients with pathology-confirmed MBO without gastric outlet obstruction. The primary outcome was technical success. Secondary outcomes included clinical success, adverse events (AEs), and reinterventions. The study was registered in the Netherlands Trial Registry (registry number NL9757). RESULTS 22 patients were enrolled (median age 69.5 years [interquartile range 64-75.3]). Technical success was achieved in 20/22 patients (91 %). AEs occurred in one patient, namely perforation following inadequate stent deployment (5 %), which was treated in the same procedure. Clinical success was achieved in 19/22 patients (86 %). Stent dysfunction was observed in 11/20 patients (55 %) after technically successful EUS-CDS: two patients were treated conservatively and nine patients underwent reintervention(s). One patient died within ≤ 30 days due to fulminant disease progression. CONCLUSIONS The results confirmed the safety and feasibility of EUS-CDS using LAMS as a primary drainage strategy. The high incidence of stent dysfunction should be improved before EUS-CDS with LAMS can be seen as a valid alternative to endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Jeska A Fritzsche
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc G Besselink
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Nahid S M Montazeri
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Biostatistics Unit, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roy L J Van Wanrooij
- Amsterdam Gastroenterology Endocrinology Metabolism, Research Institute, Amsterdam, The Netherlands
- Treatment and Quality of life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
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17
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van Goor IW, Schouten TJ, Verburg DN, Besselink MG, Bonsing BA, Bosscha K, Brosens LA, Busch OR, Cirkel GA, van Dam RM, Festen S, Koerkamp BG, van der Harst E, de Hingh IH, Intven MP, Kazemier G, Los M, Meijer GJ, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JM, Stommel MW, Verdonk RC, van Santvoort HC, Daamen LA, Molenaar IQ. Predicting Long-term Disease-free Survival After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Cohort Study. Ann Surg 2024; 279:132-137. [PMID: 37450706 PMCID: PMC10727199 DOI: 10.1097/sla.0000000000006004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To develop a prediction model for long-term (≥5 years) disease-free survival (DFS) after the resection of pancreatic ductal adenocarcinoma (PDAC). BACKGROUND Despite high recurrence rates, ~10% of patients have long-term DFS after PDAC resection. A model to predict long-term DFS may aid individualized prognostication and shared decision-making. METHODS This nationwide cohort study included all consecutive patients who underwent PDAC resection in the Netherlands (2014-2016). The best-performing prognostic model was selected by Cox-proportional hazard analysis and Akaike's Information Criterion, presented by hazard ratios (HRs) with 95% confidence intervals (CIs). Internal validation was performed, and discrimination and calibration indices were assessed. RESULTS In all, 836 patients with a median follow-up of 67 months (interquartile range 51-79) were analyzed. Long-term DFS was seen in 118 patients (14%). Factors predictive of long-term DFS were low preoperative carbohydrate antigen 19-9 (logarithmic; HR 1.21; 95% CI 1.10-1.32), no vascular resection (HR 1.33; 95% CI 1.12-1.58), T1 or T2 tumor stage (HR 1.52; 95% CI 1.14-2.04, and HR 1.17; 95% CI 0.98-1.39, respectively), well/moderate tumor differentiation (HR 1.44; 95% CI 1.22-1.68), absence of perineural and lymphovascular invasion (HR 1.42; 95% CI 1.11-1.81 and HR 1.14; 95% CI 0.96-1.36, respectively), N0 or N1 nodal status (HR 1.92; 95% CI 1.54-2.40, and HR 1.33; 95% CI 1.11-1.60, respectively), R0 resection margin status (HR 1.25; 95% CI 1.07-1.46), no major complications (HR 1.14; 95% CI 0.97-1.35) and adjuvant chemotherapy (HR 1.74; 95% CI 1.47-2.06). Moderate performance (concordance index 0.68) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS The developed prediction model, readily available at www.pancreascalculator.com, can be used to estimate the probability of long-term DFS after resection of pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Iris W.J.M. van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Thijs J. Schouten
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Daphne N. Verburg
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center 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
| | - Lodewijk A.A. Brosens
- Department of Pathology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Geert A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & Meander Medical Center Amersfoort, Utrecht, the Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Martijn P.W. Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Maartje Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, the Netherlands
| | - Vincent E. de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Daphne Roos
- Department of Surgery, Renier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Imaging Division, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
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18
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van Ramshorst TME, van Hilst J, Bannone E, Pulvirenti A, Asbun HJ, Boggi U, Busch OR, Dokmak S, Edwin B, Hogg M, Jang JY, Keck T, Khatkov I, Kohan G, Kokudo N, Kooby DA, Nakamura M, Primrose JN, Siriwardena AK, Toso C, Vollmer CM, Zeh HJ, Besselink MG, Abu Hilal M. International survey on opinions and use of robot-assisted and laparoscopic minimally invasive pancreatic surgery: 5-year follow up. HPB (Oxford) 2024; 26:63-72. [PMID: 37739876 DOI: 10.1016/j.hpb.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Evidence on the value of minimally invasive pancreatic surgery (MIPS) has been increasing but it is unclear how this has influenced the view of pancreatic surgeons on MIPS. METHODS An anonymous survey was sent to members of eight international Hepato-Pancreato-Biliary Associations. Outcomes were compared with the 2016 international survey. RESULTS Overall, 315 surgeons from 47 countries participated. The median volume of pancreatic resections per center was 70 (IQR 40-120). Most surgeons considered minimally invasive distal pancreatectomy (MIDP) superior to open (ODP) (94.6%) and open pancreatoduodenectomy (OPD) superior to minimally invasive (MIPD) (67.9%). Since 2016, there has been an increase in the number of surgeons performing both MIDP (79%-85.7%, p = 0.024) and MIPD (29%-45.7%, p < 0.001), and an increase in the use of the robot-assisted approach for both MIDP (16%-45.6%, p < 0.001) and MIPD (23%-47.9%, p < 0.001). The use of laparoscopy remained stable for MIDP (91% vs. 88.1%, p = 0.245) and decreased for MIPD (51%-36.8%, p = 0.024). CONCLUSION This survey showed considerable changes of MIPS since 2016 with most surgeons considering MIDP superior to ODP and an increased use of robot-assisted MIPS. Surgeons prefer OPD and therefore the value of MIPD remains to be determined in randomized trials.
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Affiliation(s)
- Tess M E van Ramshorst
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Jony van Hilst
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Elisa Bannone
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Alessandra Pulvirenti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Ugo Boggi
- Department of Surgery, University Hospital of Pisa, Pisa, Italy
| | - Olivier R Busch
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, APHP Beaujon Hospital - University of Paris Cité, Clichy, France
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Also Institute of Medicine, University of Oslo, Norway
| | - Melissa Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Gustavo Kohan
- Department of Surgery, Hospital Cosme Argerich, University of Buenos Aires, Buenos Aires, Argentina
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - David A Kooby
- Department of Surgery, Winship Cancer Institute, Emory University Hospital, Atlanta, GA, USA
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Christian Toso
- Division of Abdominal Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Charles M Vollmer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Herbert J Zeh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
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19
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Montorsi RM, Xenaki S, Festen S, Fockens P, Bastiaansen BAJ, Daams F, Busch OR, Besselink MG. Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis. J Vis Exp 2023. [PMID: 38163262 DOI: 10.3791/65742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.
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Affiliation(s)
- Roberto Maria Montorsi
- Amsterdam UMC, Department of Surgery, University of Amsterdam; Cancer Center Amsterdam; Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust
| | - Sofia Xenaki
- Amsterdam UMC, Department of Surgery, University of Amsterdam; Cancer Center Amsterdam; Department of General Surgery, University Hospital of Heraklion Crete
| | | | - Paul Fockens
- Cancer Center Amsterdam; Amsterdam UMC, Department of Gastroenterology, University of Amsterdam
| | - Barbara A J Bastiaansen
- Cancer Center Amsterdam; Amsterdam UMC, Department of Gastroenterology, University of Amsterdam
| | - Freek Daams
- Cancer Center Amsterdam; Amsterdam UMC, Department of Surgery, Vrije Universiteit
| | - Olivier R Busch
- Amsterdam UMC, Department of Surgery, University of Amsterdam; Cancer Center Amsterdam
| | - M G Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam; Cancer Center Amsterdam;
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20
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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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Schouten TJ, Henry AC, Smits FJ, Besselink MG, Bonsing BA, Bosscha K, Busch OR, van Dam RM, van Eijck CH, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, de Meijer VE, Patijn GA, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Daamen LA, Molenaar IQ, van Santvoort HC. Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort. Ann Surg 2023; 278:1001-1008. [PMID: 36804843 DOI: 10.1097/sla.0000000000005824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF). BACKGROUND Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models. METHODS A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF. RESULTS Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF. CONCLUSION Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.
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Affiliation(s)
- Thijs J Schouten
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Anne Claire Henry
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Francina J Smits
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, 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, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ignace H J T de Hingh
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Cancer Center, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Lois A Daamen
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Izaak Q Molenaar
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
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22
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Chen JW, Lof S, Zwart MJW, Busch OR, Daams F, Festen S, Fong ZV, Hogg ME, Slooter MD, Nieveen van Dijkum EJ, Besselink MG. Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study. Ann Surg Open 2023; 4:e354. [PMID: 38144496 PMCID: PMC10735109 DOI: 10.1097/as9.0000000000000354] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023] Open
Abstract
Background A potential downside of robotic pancreatoduodenectomy (RPD) is the lack of tactile feedback when tying sutures, which could be especially perilous during pancreatic anastomosis. Near-infrared fluorescence imaging with indocyanine green (NIRF-ICG) could detect transpancreatic-suture-induced hypoperfusion of the pancreatic stump during RPD, which may be related to postoperative pancreatic fistula (POPF) grade B/C, but studies are lacking. Methods This prospective study included 37 patients undergoing RPD to assess the relation between pancreatic stump hypoperfusion as objectified with NIRF-ICG using Firefly and the rate of POPF grade B/C. In 27 patients, NIRF-ICG was performed after tying down the transpancreatic U-sutures. In 10 'negative control' patients, NIRF-ICG was performed before tying these sutures. Results Pancreatic stump hypoperfusion was detected using NIRF-ICG in 9/27 patients (33%) during RPD. Hypoperfusion was associated with POPF grade B/C (67% [6/9 patients] versus 17% [3/18 patients], P = 0.026). No hypoperfusion was objectified in 10 'negative controls'. Conclusions Transpancreatic-suture-induced pancreatic stump hypoperfusion can be detected using NIRF-ICG during RPD and was associated with POPF grade B/C. Surgeons could use NIRF-ICG to adapt their suturing approach during robotic pancreatico-jejunostomy. Further larger prospective studies are needed to validate the association between transpancreatic-suture-induced hypoperfusion and POPF.
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Affiliation(s)
- Jeffrey W. Chen
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Sanne Lof
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Maurice J. W. Zwart
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Olivier R. Busch
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, OLVG, Location Oost, Amsterdam, The Netherlands
| | - Zhi Ven Fong
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Maxime D. Slooter
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Els J.M. Nieveen van Dijkum
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Marc G. Besselink
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
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23
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Zwart MJ, van den Broek B, de Graaf N, Suurmeijer JA, Augustinus S, te Riele WW, van Santvoort HC, Hagendoorn J, Borel Rinkes IH, van Dam JL, Takagi K, Tran KT, Schreinemakers J, van der Schelling G, Wijsman JH, de Wilde RF, Festen S, Daams F, Luyer MD, de Hingh IH, Mieog JS, Bonsing BA, Lips DJ, Abu Hilal M, Busch OR, Saint-Marc O, Zeh HJ, Zureikat AH, Hogg ME, Koerkamp BG, Molenaar IQ, Besselink MG. The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants". Ann Surg 2023; 278:e1232-e1241. [PMID: 37288547 PMCID: PMC10631507 DOI: 10.1097/sla.0000000000005928] [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] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the feasibility, proficiency, and mastery learning curves for robotic pancreatoduodenectomy (RPD) in "second-generation" RPD centers following a multicenter training program adhering to the IDEAL framework. BACKGROUND The long learning curves for RPD reported from "pioneering" expert centers may discourage centers interested in starting an RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in "second-generation" centers that participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in "second-generation" centers trained in a dedicated nationwide program. METHODS Post hoc analysis of all consecutive patients undergoing RPD in 7 centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum analysis determined cutoffs for the 3 learning curves: operative time for the feasibility (1) risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency, (2) and textbook outcome for the mastery, (3) learning curve. Outcomes before and after the cutoffs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued "lessons learned." RESULTS Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016 to 2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic pancreatoduodenectomy decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cutoffs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cutoffs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome. CONCLUSIONS The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in "second-generation" centers after a multicenter training program were considerably shorter than previously reported from "pioneering" expert centers. The learning curve cutoffs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.
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Affiliation(s)
- Maurice J.W. Zwart
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Bram van den Broek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Nine de Graaf
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
| | - José A. Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Simone Augustinus
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Wouter W. te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H.M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L. van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Khé T.C. Tran
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Jan H. Wijsman
- Department of Surgery, Amphia Medical Center, Breda, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Misha D. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S.D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Twente Medical Spectrum, Enschede, the Netherlands
| | - Mohamed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Institute, Brescia, Italy
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Herbert J. Zeh
- Department of Surgery, University of Texas, Southwestern, Dallas, TX
| | - Amer H. Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Bas G. Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Isaac Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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Montorsi RM, Zonderhuis BM, Daams F, Busch OR, Kazemier G, Marchegiani G, Malleo G, Salvia R, Besselink MG. Treatment strategies to prevent or mitigate the outcome of post-pancreatectomy hemorrhage (PPH): a review of randomized trials. Int J Surg 2023:01279778-990000000-00779. [PMID: 37983766 DOI: 10.1097/js9.0000000000000876] [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] [Received: 08/30/2023] [Accepted: 10/22/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Post-pancreatectomy hemorrhage (PPH) is a leading cause for surgical mortality after pancreatic surgery. Several strategies for the prevention and management of PPH have been studied in randomized controlled trials (RCTs) but a systematic review is lacking. We systematically reviewed RCTs regarding the impact of treatment strategies on the incidence and outcome of PPH. MATERIAL AND METHODS Eligible RCTs reporting on impact of treatment on the rate of PPH were identified through a systematic literature search using the Evidence Map of Pancreatic Surgery (2012-2022). Methodological quality was assessed using the Cochrane Risk of Bias 2 (RoB-2) tool for RCTs. Various definitions of PPH were accepted and outcome reported separately for the International Study Group for Pancreatic Surgery (ISGPS) definition. RESULTS Overall, 99 RCTs fulfilled the eligibility criteria with a pooled 6.1% rate of PPH (range 1%-32%). The pooled rate of PPH defined as ISGPS grade B/C was 8.1% (range 0-24.9%). Five RCTs reported five strategies that significantly reduced the rate of PPH. Three concerned surgical technique: pancreatic anastomosis with small jejunal incision, falciform ligament wrap around the gastroduodenal artery stump, and pancreaticojejunostomy (vs pancreaticogastrostomy). Two concerned perioperative management: perioperative pasireotide administration, and algorithm-based postoperative patient management. No single RCT specifically focused on the treatment of patients with PPH. CONCLUSION This systematic review of RCTs identified five strategies which reduce the rate of PPH; three concerning intraoperative surgical technique and two concerning peri-operative patient management. Future studies should focus on the treatment of patients with PPH as RCTs are currently lacking.
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Affiliation(s)
- Roberto M Montorsi
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Babs M Zonderhuis
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
| | - Freek Daams
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
| | - Geert Kazemier
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
| | - Giovanni Marchegiani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Via Giustiniani 2, 35134, Padua, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
- Cancer Center Amsterdam, De Boelelaan 1118, 1081 HV Amsterdam, the Netherlands
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25
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Augustinus S, Busch OR, Bonsing BA, Bruno MJ, de Groot JWB, Groot Koerkamp B, Intven MPW, Köhler F, Molenaar Q, Wilmink JW, Besselink MG. [Nationwide multidisciplinary developments in pancreatic cancer care in the Netherlands]. Ned Tijdschr Geneeskd 2023; 167:D7435. [PMID: 37994711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
In the past years several developments have occurred in the care for patients with pancreatic cancer in the Netherlands. New palliative chemotherapy strategies using FOLFRINOX or gemcitabine/nab-paclitaxel were introduced for patients with advanced disease. Due to centralization of pancreatic surgery, introduction of neoadjuvant therapy, and the implementation of standardized postoperative care more patients became enable for resection, postoperative mortality decreased, and survival improved. Within the randomized PREOPANC trial of the Dutch Pancreatic Cancer Group (DPCG), neoadjuvant therapy using chemoradiation for (borderline) resectable pancreatic cancer improved five-year survival from 7% to 21%. Furthermore, due to nationwide training programs, the use of minimally invasive surgery has increased. Regardless of these developments, the survival of patients with pancreatic cancer is still low and 61% of Dutch patients with pancreatic cancer patients do not receive any tumor targeted therapy. The DPCG is active to improve quality of care through auditing, research, guideline development, and education.
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26
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Seelen LWF, Molenaar IQ, de Wilde RF, Wilmink JW, Busch OR, van Santvoort HC. [Resection of locally advanced pancreatic cancer: careful selection and shared decision making]. Ned Tijdschr Geneeskd 2023; 167:D7654. [PMID: 37994726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
The landscape regarding the treatment possibilities for patients with locally advanced pancreatic cancer (LAPC) has changed over the last decade. The introduction of modern multi-agent chemotherapeutic regimens (i.e., FOLFIRINOX and gemcitabine/nab-paclitaxel) has improved outcomes. A minority, but still a substantial group of patients, nowadays undergo surgical resection after induction chemotherapy, providing a chance of long-term overall survival comparable to (borderline) resectable pancreatic cancer. However, selecting appropriate candidates for surgery after induction chemotherapy remains challenging, as surgery includes substantial risks which should not outweigh the potential survival benefit. Shared decision making is crucial as patients usually overestimate the value of resection. Here, we present two patients with LAPC who underwent surgical resection, but both with various work-up strategies, leading to different outcomes. These patients highlight the importance of a multidisciplinary approach to select appropriate candidates for the best treatment option, avoiding futile surgery.
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27
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Augustinus S, Mackay TM, Andersson B, Beane JD, Busch OR, Gleeson EM, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Wellner UF, Williamsson C, Besselink MG, Pitt HA. Ideal Outcome After Pancreatoduodenectomy: A Transatlantic Evaluation of a Harmonized Composite Outcome Measure. Ann Surg 2023; 278:740-747. [PMID: 37476990 PMCID: PMC10549886 DOI: 10.1097/sla.0000000000006037] [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] [Indexed: 07/22/2023]
Abstract
OBJECTIVE The aim of this study is to define and assess Ideal Outcome in the national or multicenter registries of North America, Germany, the Netherlands, and Sweden. BACKGROUND Assessing outcomes after pancreatoduodenectomy among centers and countries requires a broad evaluation that cannot be captured by a single parameter. Previously, 2 composite outcome measures (textbook outcome and optimal pancreatic surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into ideal outcome (IO). METHODS This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, The Netherlands, and Sweden. After 3 consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all 6 parameters: (1) in-hospital mortality, (2) severe complications-Clavien-Dindo ≥3, (3) postoperative pancreatic fistula-International Study Group of Pancreatic Surgery (ISGPS) grade B/C, (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative largest difference (RLD) and absolute largest difference (ALD), and multivariate regression models. RESULTS Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in The Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P <0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of chronic obstructive pulmonary disease, body mass index, performance status, American Society of Anesthesiologists (ASA) score, biliary drainage, absence of vascular resection, and histologic diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country, and neoadjuvant chemotherapy also was associated with improved IO. CONCLUSIONS The newly developed composite outcome measure "Ideal Outcome" can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve the outcomes of pancreatic surgery.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tara M. Mackay
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Joal D. Beane
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Bas G. Koerkamp
- Department of Surgery, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tobias Keck
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulrich F. Wellner
- DGAV StuDoQ|Pancreas and Clinic of Surgery, UKSH Campus, Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Zwart ES, van Ee T, Doppenberg D, Farina A, Wilmink JW, Versteijne E, Busch OR, Besselink MG, Meijer LL, van Kooyk Y, Mebius RE, Kazemier G. The immune microenvironment after neoadjuvant therapy compared to upfront surgery in patients with pancreatic cancer. J Cancer Res Clin Oncol 2023; 149:14731-14743. [PMID: 37587309 PMCID: PMC10603010 DOI: 10.1007/s00432-023-05219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Patients with resectable and borderline resectable pancreatic ductal adenocarcinoma increasingly receive neoadjuvant therapy prior to surgery. However, the effect of neoadjuvant therapy on the immune microenvironment remains largely unknown. We analyzed the immune microenvironment in pancreatic cancer tumor tissue samples from patients treated with neoadjuvant therapy compared to patients after upfront surgery to gain knowledge about the immunological environment after therapy. METHODS Multispectral imaging was performed on tissue from resected specimens from patients with PDAC who underwent upfront surgery (n = 10), neoadjuvant FOLFIRINOX (n = 10) or gemcitabine + radiotherapy (gem-RT) (n = 9) followed by surgery. The samples were selected by a dedicated pancreas pathologist from both the central part and the invasive front of the tumor (by the resected vein or venous surface) and subsequently analyzed using the Vectra Polaris. RESULTS Patients receiving neoadjuvant FOLFIRINOX display a more pro-inflammatory immune profile, with less regulatory T cells and more CD8 T cells in the tumor tissue compared to patients receiving neoadjuvant gem-RTgem-RT or undergoing upfront surgery. Furthermore, CD163+ macrophages were decreased, and a higher CD163- macrophages versus CD163+ macrophages ratio was found in patients with neoadjuvant FOLFIRINOX. In all treatment groups, percentage of FoxP3+ B cells was significantly higher in tumor tissue compared to adjacent tissue. Furthermore, an increase in regulatory T cells in the tumor tissue was found in patients undergoing upfront surgery or receiving neoadjuvant gem-RT. In the gem-RT group, less CD8 T cells and a higher CD163+ macrophages to CD8 ratio were noted in the tumor tissue, suggesting a more immune suppressive profile in the tumor tissue. CONCLUSION Patients receiving neoadjuvant FOLFIRINOX display a more pro-inflammatory immune profile compared to patients receiving neoadjuvant gem-RT or undergoing upfront surgery. Furthermore, in all treatment groups, a more immune suppressive microenvironment was found in the tumor tissue compared to the adjacent non-tumorous tissue.
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Affiliation(s)
- Eline S Zwart
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Biology and Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Thomas van Ee
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Biology and Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Oncology Graduate School, Amsterdam, The Netherlands
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva Versteijne
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura L Meijer
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Yvette van Kooyk
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Biology and Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Reina E Mebius
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Biology and Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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29
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van den Broek BL, Zwart MJ, Bonsing BA, Busch OR, van Dam JL, de Hingh IH, Hogg ME, Luyer MD, Mieog JD, Stibbe LA, Takagi K, Tran TCK, de Wilde RF, Zeh HJ, Zureikat AH, Groot Koerkamp B, Besselink MG. Video Grading of Pancreatic Anastomoses During Robotic Pancreatoduodenectomy to Assess Both Learning Curve and the Risk of Pancreatic Fistula: A Post Hoc Analysis of the LAELAPS-3 Training Program. Ann Surg 2023; 278:e1048-e1054. [PMID: 36727842 PMCID: PMC10549894 DOI: 10.1097/sla.0000000000005796] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the learning curve of pancreaticojejunostomy during robotic pancreatoduodenectomy (RPD) and to predict the risk of postoperative pancreatic fistula (POPF) by using the objective structured assessment of technical skills (OSATS), taking the fistula risk into account. BACKGROUND RPD is a challenging procedure that requires extensive training and confirmation of adequate surgical performance. Video grading, modified for RPD, of the pancreatic anastomosis could assess the learning curve of RPD and predict the risk of POPF. METHODS Post hoc assessment of patients prospectively included in 4 Dutch centers in a nationwide LAELAPS-3 training program for RPD. Video grading of the pancreaticojejunostomy was performed by 2 graders using OSATS (attainable score: 12-60). The main outcomes were the combined OSATS of the 2 graders and POPF (grade B/C). Cumulative sum analyzed a turning point in the learning curve for surgical skill. Logistic regression determined the cutoff for OSATS. Patients were categorized for POPF risk (ie, low, intermediate, and high) based on the updated alternative fistula risk scores. RESULTS Videos from 153 pancreatic anastomoses were included. Median OSATS score was 48 (interquartile range: 41-52) points and with a turning point at 33 procedures. POPF occurred in 39 patients (25.5%). An OSATS score below 49, present in 77 patients (50.3%), was associated with an increased risk of POPF (odds ratio: 4.01, P =0.004). The POPF rate was 43.6% with OSATS < 49 versus 15.8% with OSATS ≥49. The updated alternative fistula risk scores category "soft pancreatic texture" was the second strongest prognostic factor of POPF (odds ratio: 3.37, P =0.040). Median cumulative surgical experience was 17 years (interquartile range: 8-21). CONCLUSIONS Video grading of the pancreatic anastomosis in RPD using OSATS identified a learning curve and a reduced risk of POPF in case of better surgical performance. Video grading may provide a valid method to surgical training, quality control, and improvement.
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Affiliation(s)
| | - Maurice J.W. Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jacob L. van Dam
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Melissa E. Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL
| | - Misha D. Luyer
- Department of Surgery, Catharina Medical Center, Eindhoven, Netherlands
| | - J.Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Luna A. Stibbe
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - T. C. Khe Tran
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amer H. Zureikat
- Department of Surgery, Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
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Mazzotta AD, VAN Bodegraven EA, Petrucciani N, Usai S, Carneiro AC, Tribillon E, Ferraz JM, Busch OR, Gayet B, Besselink MG, Soubrane O. Oncological Outcome After Laparoscopic 'No-touch' RAMPS Versus 'Touch' Left Pancreatectomy for Pancreatic Adenocarcinoma. Anticancer Res 2023; 43:4983-4991. [PMID: 37909963 DOI: 10.21873/anticanres.16697] [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: 08/15/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND/AIM The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a "no-touch" technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aimed to evaluate the oncological outcomes of the laparoscopic "no touch" technique versus the "touch" technique. PATIENTS AND METHODS From 2001 to 2020, we retrospectively analyzed 45 patients undergoing laparoscopic distal pancreatectomy (LDP) for PDAC in two centers. Factors associated with overall (OS), disease-free survival (DFS) and time to recurrence (TTR) were identified. RESULTS The OS rates in the 'no-touch' and 'touch' groups were 95% vs. 78% (1-year OS); 50% vs. 50% (3-year OS), respectively (p=0.60). The DFS rates in the 'no-touch' and 'touch' groups were 72 % vs. 57% (1-year DFS); 32% vs. 28% (3-year DFS), respectively (p=0.11). The TTR rates in the 'no-touch' and 'touch' groups were 77% vs. 61% (1-year TTR); 54% vs. 30% (3-year TTR); 46% vs. 11% (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique [odds ratio (OR)=2.62, p=0.02] and lymphovascular emboli (OR=4.8; p=0.002). CONCLUSION We advise the 'no-touch' technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the 'no-touch' technique in this setting although there could be oncological benefits.
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Affiliation(s)
- Alessandro D Mazzotta
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France;
| | - Eduard A VAN Bodegraven
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Niccolo Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University, Rome, Italy
| | - Sofia Usai
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Adriano Costa Carneiro
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Ecoline Tribillon
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Jean Marc Ferraz
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Olivier R Busch
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Brice Gayet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Marc G Besselink
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Olivier Soubrane
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
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de Graaf N, Emmen AMLH, Ramera M, Björnsson B, Boggi U, Bruna CL, Busch OR, Daams F, Ferrari G, Festen S, van Hilst J, D'Hondt M, Ielpo B, Keck T, Khatkov IE, Koerkamp BG, Lips DJ, Luyer MDP, Mieog JSD, Morelli L, Molenaar IQ, van Santvoort HC, Sprangers MAG, Ferrari C, Berkhof J, Maisonneuve P, Abu Hilal M, Besselink MG. Minimally invasive versus open pancreatoduodenectomy for pancreatic and peri-ampullary neoplasm (DIPLOMA-2): study protocol for an international multicenter patient-blinded randomized controlled trial. Trials 2023; 24:665. [PMID: 37828593 PMCID: PMC10571285 DOI: 10.1186/s13063-023-07657-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) aims to reduce the negative impact of surgery as compared to open pancreatoduodenectomy (OPD) and is increasingly becoming part of clinical practice for selected patients worldwide. However, the safety of MIPD remains a topic of debate and the potential shorter time to functional recovery needs to be confirmed. To guide safe implementation of MIPD, large-scale international randomized trials comparing MIPD and OPD in experienced high-volume centers are needed. We hypothesize that MIPD is non-inferior in terms of overall complications, but superior regarding time to functional recovery, as compared to OPD. METHODS/DESIGN The DIPLOMA-2 trial is an international randomized controlled, patient-blinded, non-inferiority trial performed in 14 high-volume pancreatic centers in Europe with a minimum annual volume of 30 MIPD and 30 OPD. A total of 288 patients with an indication for elective pancreatoduodenectomy for pre-malignant and malignant disease, eligible for both open and minimally invasive approach, are randomly allocated for MIPD or OPD in a 2:1 ratio. Centers perform either laparoscopic or robot-assisted MIPD based on their surgical expertise. The primary outcome is the Comprehensive Complication Index (CCI®), measuring all complications graded according to the Clavien-Dindo classification up to 90 days after surgery. The sample size is calculated with the following assumptions: 2.5% one-sided significance level (α), 80% power (1-β), expected difference of the mean CCI® score of 0 points between MIPD and OPD, and a non-inferiority margin of 7.5 points. The main secondary outcome is time to functional recovery, which will be analyzed for superiority. Other secondary outcomes include post-operative 90-day Fitbit™ measured activity, operative outcomes (e.g., blood loss, operative time, conversion to open surgery, surgeon-reported outcomes), oncological findings in case of malignancy (e.g., R0-resection rate, time to adjuvant treatment, survival), postoperative outcomes (e.g., clinically relevant complications), healthcare resource utilization (length of stay, readmissions, intensive care stay), quality of life, and costs. Postoperative follow-up is up to 36 months. DISCUSSION The DIPLOMA-2 trial aims to establish the safety of MIPD as the new standard of care for this selected patient population undergoing pancreatoduodenectomy in high-volume centers, ultimately aiming for superior patient recovery. TRIAL REGISTRATION ISRCTN27483786. Registered on August 2, 2023.
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Affiliation(s)
- Nine de Graaf
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy.
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Anouk M L H Emmen
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Ramera
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
| | | | - Ugo Boggi
- Department of Surgery, Universitá Di Pisa, Pisa, Italy
| | - Caro L Bruna
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | | | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | | | | | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Clarissa Ferrari
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Mohammad Abu Hilal
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy.
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
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32
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Groen JV, Michiels N, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer: A nationwide cohort study. Surgery 2023; 174:924-933. [PMID: 37451894 DOI: 10.1016/j.surg.2023.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/19/2023] [Accepted: 06/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Practice variation exists in venous resection during pancreatoduodenectomy, but little is known about the potential causes and consequences as large studies are lacking. This study explores the potential causes and consequences of practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer in the Netherlands. METHODS This nationwide retrospective cohort study included patients undergoing pancreatoduodenectomy for pancreatic cancer in 18 centers from 2013 through 2017. RESULTS Among 1,311 patients undergoing pancreatoduodenectomy, 351 (27%) had a venous resection, and the overall median annual center volume of venous resection was 4. No association was found between the center volume of pancreatoduodenectomy and the rate of venous resections, nor between patient and tumor characteristics and the rate of venous resections per center. Female sex, lower body mass index, neoadjuvant therapy, venous involvement, and stenosis on imaging were predictive for venous resection. Adjusted for these factors, 3 centers performed significantly more, and 3 centers performed significantly fewer venous resections than expected. In patients with venous resection, significantly less major morbidity (22% vs 38%) and longer overall survival (median 16 vs 12 months) were observed in centers with an above-median annual volume of venous resections (>4). CONCLUSION Patient and tumor characteristics did not explain significant practice variation between centers in the Netherlands in venous resection during pancreatoduodenectomy for pancreatic cancer. The clinical outcomes of venous resection might be related to the volume of the procedure.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, Maastricht UMC+, The Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, The Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, The Netherlands
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33
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Doppenberg D, van Dam JL, Han Y, Bonsing BA, Busch OR, Festen S, van der Harst E, de Hingh IH, Homs MYV, Kwon W, Lee M, Lips DJ, de Meijer VE, Molenaar IQ, Nuyttens JJ, Patijn GA, van Roessel S, van der Schelling GP, Suker M, Versteijne E, de Vos-Geelen J, Wilmink JW, van Eijck CHJ, van Tienhoven G, Jang JY, Besselink MG, Groot Koerkamp B. Predictive value of baseline serum carbohydrate antigen 19-9 level on treatment effect of neoadjuvant chemoradiotherapy in patients with resectable and borderline resectable pancreatic cancer in two randomized trials. Br J Surg 2023; 110:1374-1380. [PMID: 37440421 PMCID: PMC10480034 DOI: 10.1093/bjs/znad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Guidelines suggest that the serum carbohydrate antigen (CA19-9) level should be used when deciding on neoadjuvant treatment in patients with resectable and borderline resectable pancreatic ductal adenocarcinoma (hereafter referred to as pancreatic cancer). In patients with resectable pancreatic cancer, neoadjuvant therapy is advised when the CA19-9 level is 'markedly elevated'. This study investigated the impact of baseline CA19-9 concentration on the treatment effect of neoadjuvant chemoradiotherapy (CRT) in patients with resectable and borderline resectable pancreatic cancers. METHODS In this post hoc analysis, data were obtained from two RCTs that compared neoadjuvant CRT with upfront surgery in patients with resectable and borderline resectable pancreatic cancers. The effect of neoadjuvant treatment on overall survival was compared between patients with a serum CA19-9 level above or below 500 units/ml using the interaction test. RESULTS Of 296 patients, 179 were eligible for analysis, 90 in the neoadjuvant CRT group and 89 in the upfront surgery group. Neoadjuvant CRT was associated with superior overall survival (HR 0.67, 95 per cent c.i. 0.48 to 0.94; P = 0.019). Among 127 patients (70, 9 per cent) with a low CA19-9 level, median overall survival was 23.5 months with neoadjuvant CRT and 16.3 months with upfront surgery (HR 0.63, 0.42 to 0.93). For 52 patients (29 per cent) with a high CA19-9 level, median overall survival was 15.5 months with neoadjuvant CRT and 12.9 months with upfront surgery (HR 0.82, 0.45 to 1.49). The interaction test for CA19-9 level exceeding 500 units/ml on the treatment effect of neoadjuvant CRT was not significant (P = 0.501). CONCLUSION Baseline serum CA19-9 level defined as either high or low has prognostic value, but was not associated with the treatment effect of neoadjuvant CRT in patients with resectable and borderline resectable pancreatic cancers, in contrast with current guideline advice.
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Affiliation(s)
- Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Youngmin Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | | | | | - Ignace H de Hingh
- Department of Surgery, Catherina Hospital, Eindhoven, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Mirang Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Oncology Centre, Zwolle, the Netherlands
| | - Stijn van Roessel
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | | | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Versteijne
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Geertjan van Tienhoven
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Piccardi M, Gentiluomo M, Bertoncini S, Pezzilli R, Erőss B, Bunduc S, Uzunoglu FG, Talar-Wojnarowska R, Vanagas T, Sperti C, Oliverius M, Aoki MN, Ermini S, Hussein T, Boggi U, Jamroziak K, Maiello E, Morelli L, Vodickova L, Di Franco G, Landi S, Szentesi A, Lovecek M, Puzzono M, Tavano F, van Laarhoven HWM, Zerbi A, Mohelnikova-Duchonova B, Stocker H, Costello E, Capurso G, Ginocchi L, Lawlor RT, Vanella G, Bazzocchi F, Izbicki JR, Latiano A, Bueno-de-Mesquita B, Ponz de Leon Pisani R, Schöttker B, Soucek P, Hegyi P, Gazouli M, Hackert T, Kupcinskas J, Poskiene L, Tacelli M, Roth S, Carrara S, Perri F, Hlavac V, Theodoropoulos GE, Busch OR, Mambrini A, van Eijck CHJ, Arcidiacono P, Scarpa A, Pasquali C, Basso D, Lucchesi M, Milanetto AC, Neoptolemos JP, Cavestro GM, Janciauskas D, Chen X, Chammas R, Goetz M, Brenner H, Archibugi L, Dannemann M, Canzian F, Tofanelli S, Campa D. Exploring the Neandertal legacy of pancreatic ductal adenocarcinoma risk in Eurasians. Biol Res 2023; 56:46. [PMID: 37574541 PMCID: PMC10424372 DOI: 10.1186/s40659-023-00457-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND The genomes of present-day non-Africans are composed of 1-3% of Neandertal-derived DNA as a consequence of admixture events between Neandertals and anatomically modern humans about 50-60 thousand years ago. Neandertal-introgressed single nucleotide polymorphisms (aSNPs) have been associated with modern human disease-related traits, which are risk factors for pancreatic ductal adenocarcinoma (PDAC), such as obesity, type 2 diabetes, and inflammation. In this study, we aimed at investigating the role of aSNPs in PDAC in three Eurasian populations. RESULTS The high-coverage Vindija Neandertal genome was used to select aSNPs in non-African populations from 1000 Genomes project phase 3 data. Then, the association between aSNPs and PDAC risk was tested independently in Europeans and East Asians, using existing GWAS data on more than 200 000 individuals. We did not find any significant associations between aSNPs and PDAC in samples of European descent, whereas, in East Asians, we observed that the Chr10p12.1-rs117585753-T allele (MAF = 10%) increased the risk to develop PDAC (OR = 1.35, 95%CI 1.19-1.54, P = 3.59 × 10-6), with a P-value close to a threshold that takes into account multiple testing. CONCLUSIONS Our results show only a minimal contribution of Neandertal SNPs to PDAC risk.
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Affiliation(s)
- Margherita Piccardi
- Department of Biology, Unit of Genetics, University of Pisa, Via Derna 1, 56126, Pisa, Italy
| | - Manuel Gentiluomo
- Department of Biology, Unit of Genetics, University of Pisa, Via Derna 1, 56126, Pisa, Italy
| | - Stefania Bertoncini
- Department of Biology, Unit of Zoology and Anthropology, University of Pisa, Pisa, Italy
| | | | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Stefania Bunduc
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Tomas Vanagas
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Cosimo Sperti
- Department DISCOG, Chirurgia Generale 1, University of Padova, Padua, Italy
| | - Martin Oliverius
- Department of Surgery, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Mateus Nóbrega Aoki
- Laboratory for Applied Science and Technology in Health, Carlos Chagas Institute, Curitiba, Brazil
| | - Stefano Ermini
- Blood Transfusion Service, Azienda Ospedaliero-Universitaria Meyer, Children's Hospital, Florence, Italy
| | - Tamás Hussein
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Ugo Boggi
- Division of General and Transplantation Surgery, University of Pisa, Pisa, Italy
| | - Krzysztof Jamroziak
- Department of Hematology, Transplantation and Internal Medicine, University of Warsaw, Warsaw, Poland
| | - Evaristo Maiello
- Department of Oncology, Fondazione IRCCS "Casa Sollievo Della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Luca Morelli
- Department of Translational Research and New Technologies in Medicine and Surgery, General Surgery Unit, University of Pisa, Pisa, Italy
| | - Ludmila Vodickova
- Department of Molecular Biology of Cancer, Institute of Experimental Medicine of the Czech Academy of Sciences, Prague, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Gregorio Di Franco
- Department of Translational Research and New Technologies in Medicine and Surgery, General Surgery Unit, University of Pisa, Pisa, Italy
| | - Stefano Landi
- Department of Biology, Unit of Genetics, University of Pisa, Via Derna 1, 56126, Pisa, Italy
| | - Andrea Szentesi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Martin Lovecek
- Department of Surgery I, University Hospital Olomouc, Olomouc, Czech Republic
| | - Marta Puzzono
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Tavano
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo Della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Alessandro Zerbi
- Pancreatic Unit, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Hannah Stocker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - Eithne Costello
- Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
- Pancreas Translational and Clinical Research Center, Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Laura Ginocchi
- Oncological Department, Oncology of Massa Carrara, ASL Toscana Nord Ovest, Massa Carrara, Italy
| | - Rita T Lawlor
- ARC-NET Research Centre and Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Giuseppe Vanella
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
- Pancreas Translational and Clinical Research Center, Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Francesca Bazzocchi
- Department of Surgery, Fondazione IRCCS "Casa Sollievo Della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Latiano
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo Della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Bas Bueno-de-Mesquita
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Ruggero Ponz de Leon Pisani
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
| | - Pavel Soucek
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Maria Gazouli
- Laboratory of Biology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lina Poskiene
- Department of Pathology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Matteo Tacelli
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Susanne Roth
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Silvia Carrara
- Department of Gastroenterology, Endoscopic Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Francesco Perri
- Division of Gastroenterology and Research Laboratory, Fondazione IRCCS "Casa Sollievo Della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, Italy
| | - Viktor Hlavac
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - George E Theodoropoulos
- First Department of Propaedeutic Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrea Mambrini
- Oncological Department, Oncology of Massa Carrara, ASL Toscana Nord Ovest, Massa Carrara, Italy
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paolo Arcidiacono
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Aldo Scarpa
- ARC-NET Research Centre and Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Claudio Pasquali
- Department DISCOG, Chirurgia Generale 3, University of Padova, Padua, Italy
| | - Daniela Basso
- Department DIMED, Laboratory Medicine, University of Padova, Padua, Italy
| | - Maurizio Lucchesi
- Oncological Department, Oncology of Massa Carrara, ASL Toscana Nord Ovest, Massa Carrara, Italy
| | | | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dainius Janciauskas
- Department of Pathology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Xuechen Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Roger Chammas
- Department of Radiology and Oncology, Institute of Cancer of São Paulo (ICESP) São Paulo, Sao Paulo, Brazil
- Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Mara Goetz
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Livia Archibugi
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
- Pancreas Translational and Clinical Research Center, Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Michael Dannemann
- Estonian Biocentre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Federico Canzian
- Genomic Epidemiology Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sergio Tofanelli
- Department of Biology, Unit of Zoology and Anthropology, University of Pisa, Pisa, Italy
| | - Daniele Campa
- Department of Biology, Unit of Genetics, University of Pisa, Via Derna 1, 56126, Pisa, Italy.
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van Dam JL, Verkolf EMM, Dekker EN, Bonsing BA, Bratlie SO, Brosens LAA, Busch OR, van Driel LMJW, van Eijck CHJ, Feshtali S, Ghorbani P, de Groot DJA, de Groot JWB, Haberkorn BCM, de Hingh IH, van der Holt B, Karsten TM, van der Kolk MB, Labori KJ, Liem MSL, Loosveld OJL, Molenaar IQ, Polée MB, van Santvoort HC, de Vos-Geelen J, Wumkes ML, van Tienhoven G, Homs MYV, Besselink MG, Wilmink JW, Groot Koerkamp B. Perioperative or adjuvant mFOLFIRINOX for resectable pancreatic cancer (PREOPANC-3): study protocol for a multicenter randomized controlled trial. BMC Cancer 2023; 23:728. [PMID: 37550634 PMCID: PMC10405377 DOI: 10.1186/s12885-023-11141-5] [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: 01/12/2023] [Accepted: 06/30/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Surgical resection followed by adjuvant mFOLFIRINOX (5-fluorouracil with leucovorin, irinotecan, and oxaliplatin) is currently the standard of care for patients with resectable pancreatic cancer. The main concern regarding adjuvant chemotherapy is that only half of patients actually receive adjuvant treatment. Neoadjuvant chemotherapy, on the other hand, guarantees early systemic treatment and may increase chemotherapy use and thereby improve overall survival. Furthermore, it may prevent futile surgery in patients with rapidly progressive disease. However, some argue that neoadjuvant therapy delays surgery, which could lead to progression towards unresectable disease and thus offset the potential benefits. Comparison of perioperative (i.e., neoadjuvant and adjuvant) with (only) adjuvant administration of mFOLFIRINOX in a randomized controlled trial (RCT) is needed to determine the optimal approach. METHODS This multicenter, phase 3, RCT will include 378 patients with resectable pancreatic ductal adenocarcinoma with a WHO performance status of 0 or 1. Patients are recruited from 20 Dutch centers and three centers in Norway and Sweden. Resectable pancreatic cancer is defined as no arterial contact and ≤ 90 degrees venous contact. Patients in the intervention arm are scheduled for 8 cycles of neoadjuvant mFOLFIRINOX followed by surgery and 4 cycles of adjuvant mFOLFIRINOX (2-week cycle of oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 150 mg/m2 at day 1, followed by 46 h continuous infusion of 5-fluorouracil 2400 g/m2). Patients in the comparator arm start with surgery followed by 12 cycles of adjuvant mFOLFIRINOX. The primary outcome is overall survival by intention-to-treat. Secondary outcomes include progression-free survival, resection rate, quality of life, adverse events, and surgical complications. To detect a hazard ratio of 0.70 with 80% power, 252 events are needed. The number of events is expected to be reached after the inclusion of 378 patients in 36 months, with analysis planned 18 months after the last patient has been randomized. DISCUSSION The multicenter PREOPANC-3 trial compares perioperative mFOLFIRINOX with adjuvant mFOLFIRINOX in patients with resectable pancreatic cancer. TRIAL REGISTRATION Clinical Trials: NCT04927780. Registered June 16, 2021.
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Affiliation(s)
- J L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E M M Verkolf
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E N Dekker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S O Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pathology, Radboud UMC, Nijmegen, The Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - L M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - S Feshtali
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - P Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - D J A de Groot
- Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - J W B de Groot
- Department of Medical Oncology, Isala Oncology Center, Zwolle, The Netherlands
| | - B C M Haberkorn
- Department of Medical Oncology, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - B van der Holt
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - T M Karsten
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - M B van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - K J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - O J L Loosveld
- Department of Medical Oncology, Amphia Hospital, Breda, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, Utrecht, The Netherlands
| | - M B Polée
- Department of Medical Oncology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, Utrecht, The Netherlands
| | - J de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, GROW, Maastricht UMC+, Maastricht, the Netherlands
| | - M L Wumkes
- Department of Medical Oncology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - G van Tienhoven
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Radiation Oncology, Location University of Amsterdam, Amsterdam, The Netherlands
| | - M Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
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36
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van Dongen JC, van Dam JL, Besselink MG, Bonsing BA, Bosscha K, Busch OR, van Dam RM, Festen S, van der Harst E, de Hingh IH, Kazemier G, Liem MSL, de Meijer VE, Mieog JSD, Molenaar IQ, Patijn GA, van Santvoort HC, Wijsman JH, Stommel MWJ, Wit F, De Wilde RF, van Eijck CHJ, Groot Koerkamp B. Fistula Risk Score for Auditing Pancreatoduodenectomy: The Auditing-FRS. Ann Surg 2023; 278:e272-e277. [PMID: 35837978 DOI: 10.1097/sla.0000000000005532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals. BACKGROUND For proper comparisons of outcomes in surgical audits, case-mix variation should be accounted for. METHODS This study included consecutive patients after pancreatoduodenectomy from the mandatory nationwide Dutch Pancreatic Cancer Audit. Derivation of the score was performed with the data from 2014 to 2018 and validation with 2019 to 2020 data. The primary endpoint of the study was POPF (grade B or C). Multivariable logistic regression analysis was performed for case-mix adjustment of known risk factors. RESULTS In the derivation cohort, 3271 patients were included, of whom 479 (14.6%) developed POPF. Male sex [odds ratio (OR)=1.34; 95% confidence interval (CI): 1.09-1.66], higher body mass index (OR=1.07; 95% CI: 1.05-1.10), a final diagnosis other than pancreatic ductal adenocarcinoma/pancreatitis (OR=2.41; 95% CI: 1.90-3.06), and a smaller duct diameter (OR=1.43/mm decrease; 95% CI: 1.32-1.55) were independently associated with POPF. Diabetes mellitus (OR=0.73; 95% CI: 0.55-0.98) was independently associated with a decreased risk of POPF. Model discrimination was good with a C -statistic of 0.73 in the derivation cohort and 0.75 in the validation cohort (n=913). Hospitals differed in particular in the proportion of pancreatic ductal adenocarcinoma/pancreatitis patients, ranging from 36.0% to 58.1%. The observed POPF risk per center ranged from 2.9% to 25.4%. The expected POPF rate based on the 5 risk factors ranged from 11.6% to 18.0% among hospitals. CONCLUSIONS The auditing fistula risk score was successful in case-mix adjustment and enables fair comparisons of POPF rates among hospitals.
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Affiliation(s)
- Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center 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, 's-Hertogenbosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Izaak Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
| | - Roeland F De Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Augustinus S, Schafrat PJM, Janssen BV, Bonsing BA, Brosens LAA, Busch OR, Crobach S, Doukas M, van Eijck CH, van der Geest LGM, Groot Koerkamp B, de Hingh IHJT, Raicu GM, van Santvoort HC, van Velthuysen ML, Verheij J, Besselink MG, Farina Sarasqueta A. ASO Visual Abstract: Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer. Ann Surg Oncol 2023; 30:5061-5062. [PMID: 37208569 DOI: 10.1245/s10434-023-13555-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pascale J M Schafrat
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Boris V Janssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - G Mihaela Raicu
- Department of Pathology, St. Antonius Hospital and Pathology DNA, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital, Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Joanne Verheij
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Arantza Farina Sarasqueta
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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Augustinus S, Schafrat PJM, Janssen BV, Bonsing BA, Brosens LAA, Busch OR, Crobach S, Doukas M, van Eijck CH, van der Geest LGM, Groot Koerkamp B, de Hingh IHJT, Raicu GM, van Santvoort HC, van Velthuysen ML, Verheij J, Besselink MG, Farina Sarasqueta A. Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer. Ann Surg Oncol 2023; 30:5051-5060. [PMID: 37210448 PMCID: PMC10319672 DOI: 10.1245/s10434-023-13465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Surgeons aim for R0 resection in patients with pancreatic cancer to improve overall survival. However, it is unclear whether recent changes in pancreatic cancer care such as centralization, increased use of neoadjuvant therapy, minimally invasive surgery, and standardized pathology reporting have influenced R0 resections and whether R0 resection remains associated with overall survival. METHODS This nationwide retrospective cohort study included consecutive patients after pancreatoduodenectomy (PD) for pancreatic cancer from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database (2009-2019). R0 resection was defined as > 1 mm tumor clearance at the pancreatic, posterior, and vascular resection margins. Completeness of pathology reporting was scored on the basis of six elements: histological diagnosis, tumor origin, radicality, tumor size, extent of invasion, and lymph node examination. RESULTS Among 2955 patients after PD for pancreatic cancer, the R0 resection rate was 49%. The R0 resection rate decreased from 68 to 43% (2009-2019, P < 0.001). The extent of resections in high-volume hospitals, minimally invasive surgery, neoadjuvant therapy, and complete pathology reports all significantly increased over time. Only complete pathology reporting was independently associated with lower R0 rates (OR 0.76, 95% CI 0.69-0.83, P < 0.001). Higher hospital volume, neoadjuvant therapy, and minimally invasive surgery were not associated with R0. R0 resection remained independently associated with improved overall survival (HR 0.72, 95% CI 0.66-0.79, P < 0.001), as well as in the 214 patients after neoadjuvant treatment (HR 0.61, 95% CI 0.42-0.87, P = 0.007). CONCLUSIONS The nationwide rate of R0 resections after PD for pancreatic cancer decreased over time, mostly related to more complete pathology reporting. R0 resection remained associated with overall survival.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Pascale J M Schafrat
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Boris V Janssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - G Mihaela Raicu
- Department of Pathology, St Antonius Hospital and Pathology DNA, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Arantza Farina Sarasqueta
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Korrel M, Jones LR, van Hilst J, Balzano G, Björnsson B, Boggi U, Bratlie SO, Busch OR, Butturini G, Capretti G, Casadei R, Edwin B, Emmen AM, Esposito A, Falconi M, Groot Koerkamp B, Keck T, de Kleine RH, Kleive DB, Kokkola A, Lips DJ, Lof S, Luyer MD, Manzoni A, Marudanayagam R, de Pastena M, Pecorelli N, Primrose JN, Ricci C, Salvia R, Sandström P, Vissers FL, Wellner UF, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial. Lancet Reg Health Eur 2023; 31:100673. [PMID: 37457332 PMCID: PMC10339208 DOI: 10.1016/j.lanepe.2023.100673] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
Background The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking. Methods In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265). Findings Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group. Interpretation This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer. Funding Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.
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Affiliation(s)
- Maarten Korrel
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Leia R. Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Jony van Hilst
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bergthor Björnsson
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier R. Busch
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Giovanni Capretti
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Bjørn Edwin
- The Intervention Center, Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anouk M.L.H. Emmen
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Ruben H.J. de Kleine
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dyre B. Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arto Kokkola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Sanne Lof
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Misha D.P. Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Nicolò Pecorelli
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - John N. Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claudio Ricci
- Division of Pancreatic Surgery IRCCS, S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Per Sandström
- Departments of Surgery, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Frederique L.I.M. Vissers
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marcel G.W. Dijkgraaf
- Amsterdam UMC, University of Amsterdam, Department of Epidemiology and Data Science, Amsterdam, the Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Seelen LWF, Floortje van Oosten A, Brada LJH, Groot VP, Daamen LA, Walma MS, van der Lek BF, Liem MSL, Patijn GA, Stommel MWJ, van Dam RM, Koerkamp BG, Busch OR, de Hingh IHJT, van Eijck CHJ, Besselink MG, Burkhart RA, Borel Rinkes IHM, Wolfgang CL, Molenaar IQ, He J, van Santvoort HC. Early Recurrence After Resection of Locally Advanced Pancreatic Cancer Following Induction Therapy: An International Multicenter Study. Ann Surg 2023; 278:118-126. [PMID: 35950757 DOI: 10.1097/sla.0000000000005666] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To establish an evidence-based cutoff and predictors for early recurrence in patients with resected locally advanced pancreatic cancer (LAPC). BACKGROUND It is unclear how many and which patients develop early recurrence after LAPC resection. Surgery in these patients is probably of little benefit. METHODS We analyzed all consecutive patients undergoing resection of LAPC after induction chemotherapy who were included in prospective databases in The Netherlands (2015-2019) and the Johns Hopkins Hospital (2016-2018). The optimal definition for "early recurrence" was determined by the post-recurrence survival (PRS). Patients were compared for overall survival (OS). Predictors for early recurrence were evaluated using logistic regression analysis. RESULTS Overall, 168 patients were included. After a median follow-up of 28 months, recurrence was observed in 118 patients (70.2%). The optimal cutoff for recurrence-free survival to differentiate between early (n=52) and late recurrence (n=66) was 6 months ( P <0.001). OS was 8.4 months [95% confidence interval (CI): 7.3-9.6] in the early recurrence group (n=52) versus 31.1 months (95% CI: 25.7-36.4) in the late/no recurrence group (n=116) ( P <0.001). A preoperative predictor for early recurrence was postinduction therapy carbohydrate antigen (CA) 19-9≥100 U/mL [odds ratio (OR)=4.15, 95% CI: 1.75-9.84, P =0.001]. Postoperative predictors were poor tumor differentiation (OR=4.67, 95% CI: 1.83-11.90, P =0.001) and no adjuvant chemotherapy (OR=6.04, 95% CI: 2.43-16.55, P <0.001). CONCLUSIONS Early recurrence was observed in one third of patients after LAPC resection and was associated with poor survival. Patients with post-induction therapy CA 19-9 ≥100 U/mL, poor tumor differentiation and no adjuvant therapy were especially at risk. This information is valuable for patient counseling before and after resection of LAPC.
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Affiliation(s)
- Leonard W F Seelen
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Anne Floortje van Oosten
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lilly J H Brada
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Marieke S Walma
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Bastiaan F van der Lek
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Inne H M Borel Rinkes
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | | | - Izaak Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein: Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
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Fong ZV, Zwart MJ, Gorris M, Voermans RP, van Wanrooij RL, Wielenga T, del Chiaro M, Arnelo U, Daams F, Busch OR, Besselink MG. Intraoperative Pancreatoscopy During Robotic Pancreatoduodenectomy and Robotic Distal Pancreatectomy for Intraductal Papillary Mucinous Neoplasm with Involvement of the Main Pancreatic Duct. Ann Surg Open 2023; 4:e283. [PMID: 37601466 PMCID: PMC10431574 DOI: 10.1097/as9.0000000000000283] [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: 11/24/2022] [Accepted: 02/02/2023] [Indexed: 08/22/2023] Open
Abstract
Background Intraductal papillary mucinous neoplasm (IPMN) with involvement of the main pancreatic duct usually requires surgical resection. Consensus is lacking whether to partially or completely resect the pancreatic portion with a dilated main pancreatic duct. Intraoperative pancreatoscopy may be useful to determine the extent of IPMN to tailor surgical resection and was recently studied in a large prospective international study. IPMN is increasingly utilized using a robotic approach. Studies describing the technical approach to intraoperative pancreatoscopy in robotic pancreatoduodenectomy and robotic distal pancreatectomy are lacking. Methods During robotic pancreatoduodenectomy, pancreatoscopy is performed once the pancreas neck is transected. The scope is advanced via a laparoscopic port into the left and right-sided pancreatic duct, guided by robotic graspers. During robotic distal pancreatectomy, pancreatoscopy is performed before complete parenchymal transection. The scope is advanced through an anterior ductotomy to examine the duct and guide the pancreatic transection line. Tips and tricks how to perform the procedure efficiently without complications are detailed. Results In total, 28 robot-assisted pancreatoscopies were performed during robotic pancreatoduodenectomy and robotic distal pancreatectomy. No intraoperative complications resulting from the intraoperative pancreatoscopy were noted. In the 2 described procedures, the added time required to perform the pancreatoscopy was 6 and 17 minutes, respectively. Both patients recovered without complication and were discharged on postoperative day 5 for the robotic pancreatoduodenectomy and day 6 for the robotic distal pancreatectomy. Conclusions Intraoperative pancreatoscopy can be safely performed during both robotic pancreatoduodenectomy and robotic distal pancreatectomy for IPMN with the involvement of the main pancreatic duct. An international prospective study has recently been completed with this technique.
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Affiliation(s)
- Zhi Ven Fong
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Dana Farber Cancer Institute, Mass General Brigham, Harvard Medical School, Boston, MA
- Cancer Center Amsterdam, the Netherlands
| | - Maurice J.W. Zwart
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Myrte Gorris
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P. Voermans
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Roy L.J. van Wanrooij
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Thijs Wielenga
- Cancer Center Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Urban Arnelo
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Freek Daams
- Cancer Center Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Olivier R. Busch
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Marc G. Besselink
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
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Michiels N, Doppenberg D, Groen JV, van Veldhuisen E, Bonsing BA, Busch OR, Crobach ASLP, van Delden OM, van Dieren S, Farina A, de Hingh IHJT, Hurks R, Nederend J, Shahbazi Feshtali S, Tank Y, Vahrmeijer AL, Wasser M, Besselink MG, Mieog JSD. Intraoperative Ultrasound During Surgical Exploration in Patients with Pancreatic Cancer and Vascular Involvement (ULTRAPANC): A Prospective Multicenter Study. Ann Surg Oncol 2023; 30:3455-3463. [PMID: 36774435 PMCID: PMC10175412 DOI: 10.1245/s10434-023-13112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/02/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Determining the resectability of pancreatic cancer with vascular involvement on preoperative computed tomography imaging remains challenging, especially following preoperative chemotherapy and chemoradiotherapy. Intraoperative ultrasound (IOUS) may provide real-time additional information, but prospective multicenter series confirming its value are lacking. PATIENTS AND METHODS This prospective multicenter study included patients undergoing surgical exploration for pancreatic cancer with vascular involvement. All patients underwent IOUS at the start of explorative laparotomy. Primary outcomes were resectability status as defined by the National Comprehensive Cancer Network and the extent of vascular involvement. RESULTS Overall, 85 patients were included, of whom 74 (87%) were post preoperative chemotherapy, and mostly following FOLFIRINOX regimen (n = 57; 76%). On the basis of preoperative imaging, 34 (40%) patients were staged as resectable (RPC), 32 (38%) borderline resectable (BRPC), and 19 (22%) locally advanced pancreatic cancer (LAPC). IOUS changed the resectability status in 32/85 (38%) patients (p < 0.001), including 8/19 (42%) patients with LAPC who were downstaged (4 to BRPC, 4 to RPC), and 22/32 (69%) patients with BRPC who were downstaged to RPC. Among patients with presumed superior mesenteric artery (SMA) involvement, 20/28 (71%) had no SMA involvement on IOUS. In 15 of these 20 patients a pancreatic resection was performed, all with R0 SMA margin. CONCLUSION IOUS during surgical exploration for pancreatic cancer and vascular involvement downstaged the resectability status in over one-third of patients, which could facilitate progress during surgical exploration. This finding should be confirmed by larger studies, including detailed pathology assessment. Trial Registration www.trialregister.nl (NL7621).
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Affiliation(s)
- Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse V. Groen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Otto M. van Delden
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rob Hurks
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - A. L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Augustinus S, Latenstein AE, Bonsing BA, Busch OR, Groot Koerkamp B, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, de Vos-Geelen J, van Eijck CH, Besselink MG. Chyle Leak After Pancreatoduodenectomy: Clinical Impact and Risk Factors in a Nationwide Analysis. Ann Surg 2023; 277:e1299-e1305. [PMID: 35786606 PMCID: PMC10174101 DOI: 10.1097/sla.0000000000005449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the clinical impact and risk factors of chyle leak (CL). BACKGROUND In 2017, the International Study Group for Pancreatic Surgery (ISGPS) published the consensus definition of CL. Multicenter series validating this definition are lacking and previous studies investigating risk factors have used different definitions and showed heterogeneous results. METHODS This observational cohort study included all consecutive patients after pancreatoduodenectomy in all 19 centers in the mandatory nationwide Dutch Pancreatic Cancer Audit (2017-2019). The primary endpoint was CL (ISGPS grade B/C). Multivariable logistic regression analyses were performed. RESULTS Overall, 2159 patients after pancreatoduodenectomy were included. The rate of CL was 7.0% (n=152), including 6.9% (n=150) grade B and 0.1% (n=2) grade C. CL was independently associated with a prolonged hospital stay [odds ratio (OR)=2.84, 95% confidence interval (CI): 1.85-4.36, P <0.001] but not with mortality (OR=0.3, 95% CI: 0.0-2.3, P =0.244). In multivariable analyses, independent predictors for CL were vascular resection (OR=2.1, 95% CI: 1.4-3.2, P <0.001) and open surgery (OR=3.5, 95% CI: 1.7-7.2, P =0.001). The number of resected lymph nodes and aortocaval lymph node sampling were not identified as predictors in multivariable analysis. CONCLUSIONS In this nationwide analysis, the rate of ISGPS grade B/C CL after pancreatoduodenectomy was 7.0%. Although CL is associated with a prolonged hospital stay, the clinical impact is relatively minor in the vast majority (>98%) of patients. Vascular resection and open surgery are predictors of CL.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anouk E.J. Latenstein
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - Casper H. van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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44
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Michiels N, Doppenberg D, Groen JV, van Veldhuisen E, Bonsing BA, Busch OR, Crobach ASLP, van Delden OM, van Dieren S, Farina A, de Hingh IHJT, Hurks R, Nederend J, Shahbazi Feshtali S, Tank Y, Vahrmeijer AL, Wasser M, Besselink MG, Mieog JSD. ASO Visual Abstract: Intraoperative Ultrasound During Surgical Exploration in Patients with Pancreatic Cancer and Vascular Involvement (ULTRAPANC)-A Prospective Multicenter Study. Ann Surg Oncol 2023; 30:3464-3465. [PMID: 36853567 DOI: 10.1245/s10434-023-13181-4] [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] [Indexed: 03/01/2023]
Affiliation(s)
- Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - A Stijn L P Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Otto M van Delden
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rob Hurks
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Martin Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
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45
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De Pastena M, van Bodegraven EA, Mungroop TH, Vissers FL, Jones LR, Marchegiani G, Balduzzi A, Klompmaker S, Paiella S, Tavakoli Rad S, Groot Koerkamp B, van Eijck C, Busch OR, de Hingh I, Luyer M, Barnhill C, Seykora T, Maxwell T T, de Rooij T, Tuveri M, Malleo G, Esposito A, Landoni L, Casetti L, Alseidi A, Salvia R, Steyerberg EW, Abu Hilal M, Vollmer CM, Besselink MG, Bassi C. Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation. Ann Surg 2023; 277:e1099-e1105. [PMID: 35797608 DOI: 10.1097/sla.0000000000005497] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. BACKGROUND POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. METHODS Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure. RESULTS Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85). CONCLUSIONS The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Leia R Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alberto Balduzzi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Shazad Tavakoli Rad
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Caleb Barnhill
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Thomas Seykora
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimiliano Tuveri
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, University of California, San Francisco, CA
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
- Department of Surgery, Southampton University, Southampton, UK
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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46
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de Bakker JK, Annelie Suurmeijer J, Toennaer JGJ, Bonsing BA, Busch OR, van Eijck CH, de Hingh IH, de Meijer VE, Quintus Molenaar I, van Santvoort HC, Stommel MW, Festen S, Harst EVD, Patijn G, Lips DJ, Den Dulk M, Bosscha K, Besselink MG, Kazemier G. ASO Visual Abstract: Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers-A Nationwide Audit Study. Ann Surg Oncol 2023; 30:2456-2457. [PMID: 36494607 DOI: 10.1245/s10434-022-12779-4] [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] [Indexed: 12/13/2022]
Affiliation(s)
- Jacob K de Bakker
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - J Annelie Suurmeijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jurgen G J Toennaer
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | | | | | - Gijs Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch ziekenhuis, Den Bosch, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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47
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de Bakker JK, Suurmeijer JA, Toennaer JGJ, Bonsing BA, Busch OR, van Eijck CH, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, Stommel MW, Festen S, van der Harst E, Patijn G, Lips DJ, Den Dulk M, Bosscha K, Besselink MG, Kazemier G. Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers: A Nationwide Audit Study. Ann Surg Oncol 2023; 30:2448-2455. [PMID: 36536196 PMCID: PMC10027630 DOI: 10.1245/s10434-022-12701-y] [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] [Received: 05/12/2022] [Accepted: 10/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical outcome after pancreatoduodenectomy for duodenal adenocarcinoma could differ from pancreatoduodenectomy for other cancers, but large multicenter series are lacking. This study aimed to determine surgical outcome in patients after pancreatoduodenectomy for duodenal adenocarcinoma, compared with other periampullary cancers, in a nationwide multicenter cohort. METHODS After pancreatoduodenectomy for cancer between 2014 and 2019, consecutive patients were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. Patients were stratified by diagnosis. Baseline, treatment characteristics, and postoperative outcome were compared between groups. The association between diagnosis and major complications (Clavien-Dindo grade III or higher) was assessed via multivariable regression analysis. RESULTS Overall, 3113 patients, after pancreatoduodenectomy for cancer, were included in this study: 264 (8.5%) patients with duodenal adenocarcinomas and 2849 (91.5%) with other cancers. After pancreatoduodenectomy for duodenal adenocarcinoma, patients had higher rates of major complications (42.8% vs. 28.6%; p < 0.001), postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grade B/C; 23.1% vs. 13.4%; p < 0.001), complication-related intensive care admission (14.3% vs. 10.3%; p = 0.046), re-interventions (39.8% vs. 26.6%; p < 0.001), in-hospital mortality (5.7% vs. 3.1%; p = 0.025), and longer hospital stay (15 days vs. 11 days; p < 0.001) compared with pancreatoduodenectomy for other cancers. In multivariable analysis, duodenal adenocarcinoma was independently associated with major complications (odds ratio 1.14, 95% confidence interval 1.03-1.27; p = 0.011). CONCLUSION Pancreatoduodenectomy for duodenal adenocarcinoma is associated with higher rates of major complications, pancreatic fistula, re-interventions, and in-hospital mortality compared with patients undergoing pancreatoduodenectomy for other cancers. These findings should be considered in patient counseling and postoperative management.
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Affiliation(s)
- Jacob K de Bakker
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J Annelie Suurmeijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Jurgen G J Toennaer
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Gijs Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch ziekenhuis, Den Bosch, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
| | - Geert Kazemier
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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48
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Napoli N, Cacace C, Kauffmann EF, Jones L, Ginesini M, Gianfaldoni C, Salamone A, Asta F, Ripolli A, Di Dato A, Busch OR, Cappelle ML, Chao YJ, de Wilde RF, Hackert T, Jang JY, Koerkamp BG, Kwon W, Lips D, Luyer MDP, Nickel F, Saint-Marc O, Shan YS, Shen B, Vistoli F, Besselink MG, Hilal MA, Boggi U. The PD-ROBOSCORE: A difficulty score for robotic pancreatoduodenectomy. Surgery 2023; 173:1438-1446. [PMID: 36973127 DOI: 10.1016/j.surg.2023.02.020] [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] [Received: 10/21/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Difficulty scoring systems are important for the safe, stepwise implementation of new procedures. We designed a retrospective observational study for building a difficulty score for robotic pancreatoduodenectomy. METHODS The difficulty score (PD-ROBOSCORE) aims at predicting severe postoperative complications after robotic pancreatoduodenectomy. The PD-ROBOSCORE was developed in a training cohort of 198 robotic pancreatoduodenectomies and was validated in an international multicenter cohort of 686 robotic pancreatoduodenectomies. Finally, all centers tested the model during the early learning curve (n = 300). Growing difficulty levels (low, intermediate, high) were defined using cut-off values set at the 33rd and 66th percentile (NCT04662346). RESULTS Factors included in the final multivariate model were a body mass index of ≥25 kg/m2 for males and ≥30 kg/m2 for females (odds ratio:2.39; P < .0001), borderline resectable tumor (odd ratio:1.98; P < .0001), uncinate process tumor (odds ratio:1.69; P < .0001), pancreatic duct size <4 mm (odds ratio:1.59; P < .0001), American Society of Anesthesiologists class ≥3 (odds ratio:1.59; P < .0001), and hepatic artery originating from the superior mesenteric artery (odds ratio:1.43; P < .0001). In the training cohort, the absolute score value (odds ratio = 1.13; P = .0089) and difficulty groups (odds ratio = 2.35; P = .041) predicted severe postoperative complications. In the multicenter validation cohort, the absolute score value predicted severe postoperative complications (odds ratio = 1.16, P < .001), whereas the difficulty groups did not (odds ratio = 1.94, P = .082). In the learning curve cohort, both absolute score value (odds ratio:1.078, P = .04) and difficulty groups (odds ratio: 2.25, P = .017) predicted severe postoperative complications. Across all cohorts, a PD-ROBOSCORE of ≥12.51 doubled the risk of severe postoperative complications. The PD-ROBOSCORE score also predicted operative time, estimated blood loss, and vein resection. The PD-ROBOSCORE predicted postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, and postoperative mortality in the learning curve cohort. CONCLUSION The PD-ROBOSCORE predicts severe postoperative complications after robotic pancreatoduodenectomy. The score is readily available via www.pancreascalculator.com.
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Affiliation(s)
- Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Concetta Cacace
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Leia Jones
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Italy
| | | | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Marie L Cappelle
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Ying Jui Chao
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Jin-Young Jang
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Wooil Kwon
- Department of Hepatobiliary and Pancreatic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orléans, France
| | - Yan-Shen Shan
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Netherlands; Cancer Center Amsterdam, Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy.
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49
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Henry AC, van Dongen JC, van Goor IWJM, Smits FJ, Nagelhout A, Besselink MG, Busch OR, Bonsing BA, Bosscha K, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IH, van der Kolk M, Liem MSL, de Meijer VE, Patijn GA, Roos D, Schreinemakers JM, Wit F, Daamen LA, van Santvoort HC, Molenaar IQ, van Eijck CHJ. Impact of complications after resection of pancreatic cancer on disease recurrence and survival, and mediation effect of adjuvant chemotherapy: nationwide, observational cohort study. BJS Open 2023; 7:7085021. [PMID: 36959099 PMCID: PMC10036251 DOI: 10.1093/bjsopen/zrac174] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND The causal pathway between complications after pancreatic cancer resection and impaired long-term survival remains unknown. The aim of this study was to investigate the impact of complications after pancreatic cancer resection on disease-free interval and overall survival, with adjuvant chemotherapy as a mediator. METHODS This observational study included all patients undergoing pancreatic cancer resection in the Netherlands (2014-2017). Clinical data were extracted from the prospective Dutch Pancreatic Cancer Audit. Recurrence and survival data were collected additionally. In causal mediation analysis, direct and indirect effect estimates via adjuvant chemotherapy were calculated. RESULTS In total, 1071 patients were included. Major complications (hazards ratio 1.22 (95 per cent c.i. 1.04 to 1.43); P = 0.015 and hazards ratio 1.25 (95 per cent c.i. 1.08 to 1.46); P = 0.003) and organ failure (hazards ratio 1.86 (95 per cent c.i. 1.32 to 2.62); P < 0.001 and hazards ratio 1.89 (95 per cent c.i. 1.36 to 2.63); P < 0.001) were associated with shorter disease-free interval and overall survival respectively. The effects of major complications and organ failure on disease-free interval (-1.71 (95 per cent c.i. -2.27 to -1.05) and -3.05 (95 per cent c.i. -4.03 to -1.80) respectively) and overall survival (-1.92 (95 per cent c.i. -2.60 to -1.16) and -3.49 (95 per cent c.i. -4.84 to -2.03) respectively) were mediated by adjuvant chemotherapy. Additionally, organ failure directly affected disease-free interval (-5.38 (95 per cent c.i. -9.27 to -1.94)) and overall survival (-6.32 (95 per cent c.i. -10.43 to -1.99)). In subgroup analyses, the association was found in patients undergoing pancreaticoduodenectomy, but not in patients undergoing distal pancreatectomy. CONCLUSION Major complications, including organ failure, negatively impact survival in patients after pancreatic cancer resection, largely mediated by adjuvant chemotherapy. Prevention or adequate treatment of complications and use of neoadjuvant treatment may improve oncological outcomes.
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Affiliation(s)
- Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Iris W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Anne Nagelhout
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center 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
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
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50
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Stoop TF, Ghorbani P, Theijse RT, van Veldhuisen CL, DeVries JH, Groot Koerkamp B, van Santvoort HC, Molenaar IQ, Busch OR, Del Chiaro M, Besselink MG. Comment on: Pancreatectomy With Islet-Autotransplantation As Alternative for Pancreatoduodenectomy in Patients With a High-Risk for Postoperative Pancreatic Fistula: The Jury Is Still Out. Ann Surg Open 2023; 4:e247. [PMID: 37600874 PMCID: PMC10431243 DOI: 10.1097/as9.0000000000000247] [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: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Thomas F. Stoop
- From the Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Rutger T. Theijse
- From the Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Charlotte L. van Veldhuisen
- From the Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. Hans DeVries
- Amsterdam UMC, location University of Amsterdam, Department of Internal Medicine, Amsterdam, The Netherlands, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht/Nieuwegein, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein, Utrecht/Nieuwegein, The Netherlands
| | - Olivier R. Busch
- From the Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, United States
| | - Marc G. Besselink
- From the Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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