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Pine JK, Haugk B, Robinson SM, Darne A, Wilson C, Sen G, French JJ, White SA, Manas DM, Charnley RM. Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions. Pancreatology 2020; 20:537-544. [PMID: 31996296 DOI: 10.1016/j.pan.2020.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/21/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). The prognostic value of resection margin status following pancreatoduodenectomy (PD) remains controversial. Standardised pathological assessment increases positive margins but limited data is available on the significance of involved margins. We investigated the impact of resection margin status in PDAC on patient outcome. METHOD We identified all patients with PD for PDAC at one pancreatic cancer centre between August 2008 and December 2014. Demographic, operative, adjuvant therapeutic and survival data was obtained. Pathology data including resection margin status of specific anatomic margins was collected and analysed. RESULTS 107 patients were included, all pathologically staged as T3 with 102 N1. 87.9% of patients were R1 of which 53.3% showed direct extension to the resection margin. Median survival for R0 patients versus R1<1 mm and R1 = 0 mm was 28.4 versus 15.4 and 25.1 versus 13.4 months. R1 = 0 mm status remained a predictor of poor outcome on multivariate analysis. Evaluation of individual margins (R1<1 mm) showed the SMV and SMA margins were associated with poorer overall survival. Multiple involved margins impacted negatively on outcome. SMA margin patient outcome with R1 = 1-1.9 mm was similar to R1=>2 mm. CONCLUSION Using an R1 definition of <1 mm and standardised pathology we demonstrate that R1 rates in PDAC can approach 90%. R1 = 0 mm remained an independent prognostic factor for overall survival. Using R1<1 mm we have shown that involvement of medial margins and multiple margins has significant negative impact on overall survival. We conclude that not all margin positivity has the same prognostic significance.
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Affiliation(s)
- J K Pine
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK.
| | - B Haugk
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - S M Robinson
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - A Darne
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - C Wilson
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - G Sen
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - J J French
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - S A White
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - D M Manas
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - R M Charnley
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
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Liu Z, Peneva IS, Evison F, Sahdra S, Mirza DF, Charnley RM, Savage R, Moss PA, Roberts KJ. Ninety day mortality following pancreatoduodenectomy in England: has the optimum centre volume been identified? HPB (Oxford) 2018; 20:1012-1020. [PMID: 29895441 DOI: 10.1016/j.hpb.2018.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/10/2018] [Accepted: 04/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mortality following pancreatoduodenectomy is related to centre volume although the optimal volume is not defined. METHODS Patients undergoing PD between 2001 and 2016 were identified from UK national databases. The effects of patient variables, centre volume and time period upon 90 day mortality were studied. RESULTS 90 day mortality (970/14,935, 6.5%) was related to advanced age, comorbidity, diagnosis, ethnicity, deprivation, centre volume and time period. Mortality rates fell markedly from 10.0% in 2001-4 to 4.1% in 2013-16. There was no difference in 90 day mortality between high (36 -60 PD per year) and very high volume (>60) centres. However, patients operated upon at very high volume centres were more elderly (66, 58 -73 vs 65, 56 -72; median, IQR; p = 0.006), deprived (38.7 vs 34.6%; p < 0.001) and co morbid (48.9 vs 46.1%; p = 0.027). CONCLUSION Although a plateau in the centre volume and mortality relationship appears to have been demonstrated those patients treated at the highest volume centres were at higher risk of mortality. This data suggests therefore that to further understand outcomes from specialist centres characteristics of the patient population should be defined, not just centre volume.
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Affiliation(s)
- Z Liu
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - I S Peneva
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - F Evison
- Department of Informatics, University Hospitals Birmingham, UK
| | - S Sahdra
- Department of Informatics, University Hospitals Birmingham, UK
| | - D F Mirza
- Department of HPB & Transplant Surgery, University Hospitals Birmingham, UK
| | - R M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - R Savage
- Depts of Statistics and Mathematics for Real World Systems CDT, University of Warwick, UK
| | - P A Moss
- School of Cancer Studies, University of Birmingham, UK
| | - K J Roberts
- Department of HPB & Transplant Surgery, University Hospitals Birmingham, UK.
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Elander NO, Aughton K, Ghaneh P, Neoptolemos JP, Palmer DH, Cox TF, Campbell F, Costello E, Halloran CM, Mackey JR, Scarfe AG, Valle JW, McDonald AC, Carter R, Tebbutt NC, Goldstein D, Shannon J, Dervenis C, Glimelius B, Deakin M, Charnley RM, Anthoney A, Lerch MM, Mayerle J, Oláh A, Büchler MW, Greenhalf W. Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy. Br J Cancer 2018; 118:1084-1088. [PMID: 29523831 PMCID: PMC5931097 DOI: 10.1038/s41416-018-0005-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma. METHODS Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups. RESULTS Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group. CONCLUSIONS Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.
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Affiliation(s)
- N O Elander
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - K Aughton
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - P Ghaneh
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J P Neoptolemos
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - D H Palmer
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - T F Cox
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - F Campbell
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - E Costello
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - C M Halloran
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J R Mackey
- Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - A G Scarfe
- Cross Cancer Institute and University of Alberta, Edmonton, Canada
| | - J W Valle
- University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - A C McDonald
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - R Carter
- Glasgow Royal Infirmary, Glasgow, UK
| | | | - D Goldstein
- Prince of Wales hospital and Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - J Shannon
- Nepean Cancer Centre and University of Sydney, Camperdown, NSW, Australia
| | | | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - M Deakin
- University Hospital, North Staffordshire, Staffordshire, UK
| | | | - A Anthoney
- St James's University Hospital, Leeds, UK
| | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - J Mayerle
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - A Oláh
- The Petz Aladar Hospital, Gyor, Hungary
| | - M W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - W Greenhalf
- Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK.
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Elander NO, Aughton K, Ghaneh P, Neoptolemos JP, Palmer DH, Cox TF, Campbell F, Costello E, Halloran CM, Mackey JR, Scarfe AG, Valle JW, McDonald AC, Carter R, Tebbutt NC, Goldstein D, Shannon J, Dervenis C, Glimelius B, Deakin M, Charnley RM, Anthoney A, Lerch MM, Mayerle J, Oláh A, Büchler MW, Greenhalf W. Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer. Br J Cancer 2018; 118:947-954. [PMID: 29515256 PMCID: PMC5931115 DOI: 10.1038/s41416-018-0004-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/21/2017] [Accepted: 01/04/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy. METHODS DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA). RESULTS DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009). CONCLUSION DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.
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Affiliation(s)
- N O Elander
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - K Aughton
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - P Ghaneh
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J P Neoptolemos
- The Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - D H Palmer
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - T F Cox
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - F Campbell
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - E Costello
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - C M Halloran
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - J R Mackey
- Cross Cancer Institute and University of Alberta, Alberta, Canada
| | - A G Scarfe
- Cross Cancer Institute and University of Alberta, Alberta, Canada
| | - J W Valle
- University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - A C McDonald
- The Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK
| | - R Carter
- Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | | | - D Goldstein
- Prince of Wales hospital and Clinical School University of New South Wales, New South Wales, Australia
| | - J Shannon
- Nepean Cancer Centre and University of Sydney, Sydney, Australia
| | | | - B Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - M Deakin
- University Hospital, North Staffordshire, UK
| | | | | | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - J Mayerle
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - A Oláh
- The Petz Aladar Hospital, Gyor, Hungary
| | - M W Büchler
- The Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - W Greenhalf
- From the Cancer Research U.K. Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK.
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5
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Oppong KW, Dawwas MF, Charnley RM, Wadehra V, Elamin K, White S, Nayar M. EUS and EUS-FNA diagnosis of suspected pancreatic cystic neoplasms: Is the sum of the parts greater than the CEA? Pancreatology 2015; 15:531-537. [PMID: 26375415 DOI: 10.1016/j.pan.2015.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts. STUDY AIMS To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values. PATIENTS AND METHODS A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis. RESULTS CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p < 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p < 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p < 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p < 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p < 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p < 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p < 0.05. CONCLUSION The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.
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Affiliation(s)
- K W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK.
| | - M F Dawwas
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - R M Charnley
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - V Wadehra
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K Elamin
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S White
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Tsirlis T, Ausania F, White SA, French JJ, Jaques BC, Charnley RM, Manas DM. Implications of the index cholecystectomy and timing of referral for radical resection of advanced incidental gallbladder cancer. Ann R Coll Surg Engl 2015; 97:131-6. [PMID: 25723690 PMCID: PMC4473390 DOI: 10.1308/003588414x14055925060073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Accepted: 10/22/2014] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection. METHODS The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed. RESULTS Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging. CONCLUSIONS In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.
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Affiliation(s)
- T Tsirlis
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - F Ausania
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - SA White
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - JJ French
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - BC Jaques
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - RM Charnley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - DM Manas
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Ozola Zalite I, Zykus R, Francisco Gonzalez M, Saygili F, Pukitis A, Gaujoux S, Charnley RM, Lyadov V. Influence of cachexia and sarcopenia on survival in pancreatic ductal adenocarcinoma: a systematic review. Pancreatology 2014; 15:19-24. [PMID: 25524484 DOI: 10.1016/j.pan.2014.11.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 10/31/2014] [Accepted: 11/18/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Cachexia affects ∼ 80% of pancreatic cancer patients. An international consensus defines cachexia as an ongoing loss of skeletal muscle mass (sarcopenia) with or without loss of fat, which impairs body functioning and cannot be reversed by conventional nutritional measures. Weight loss percentage and elevated inflammation markers have been employed to define this condition earlier. This review aimed to assess the prevalence and consequences of cachexia and sarcopenia on survival in patients with pancreatic ductal adenocarcinoma. METHODS The systematic review was performed by searching the articles with preset terms published in PubMed and Cochrane Database until December 2013. After identifying relevant titles, abstracts were read and eligible articles data retrieved on preformatted sheets. The prevalence and impact of sarcopenia/cachexia on survival was evaluated. RESULTS In total 1145 articles were retrieved, only 10 were eligible. Definitions of cachexia and sarcopenia were heterogeneous. In patients with normal weight (BMI 18.5-24.9 kg/m(2)) the prevalence of sarcopenia ranged from 29.7 to 65%. In overweight or obese patients (BMI >25 kg/m(2)) were 16.2%-67%. Sarcopenia alone was not demonstrated to be an independent factor of decreased survival, although obese sarcopenic patients were shown to have significantly worse survival in two studies. CONCLUSIONS Impact of cachexia and sarcopenia on survival in pancreatic ductal adenocarcinoma is currently understudied in the available literature. Definitive association between cachexia and survival cannot be drawn from available studies, although weight loss and sarcopenic obesity might be considered as poor prognostic factors. Further prospective trials utilizing the consensus definition of cachexia and including other confounding factors are needed to investigate the impact of cachexia and sarcopenia on survival in pancreatic adenocarcinoma.
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Affiliation(s)
- I Ozola Zalite
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - R Zykus
- Hospital of Lithuanian University of Health Sciences Kaunas, Lithuania
| | | | - F Saygili
- Department of Gastroenterology Pamukkale University, Denizli, Turkey
| | - A Pukitis
- Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - S Gaujoux
- Department of Digestive and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Faculté de Medecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - R M Charnley
- North East's Hepato-Pancreato-Biliary Centre at the Freeman Hospital, Newcastle, United Kingdom
| | - V Lyadov
- Department of Surgical Oncology, Medical and Rehabilitation Center under the Ministry of Health of Russian Federation, Moscow, Russia.
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8
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Rehman S, John SKP, Lochan R, Jaques BC, Manas DM, Charnley RM, French JJ, White SA. Oncological feasibility of laparoscopic distal pancreatectomy for adenocarcinoma: a single-institution comparative study. World J Surg 2014; 38:476-83. [PMID: 24081543 DOI: 10.1007/s00268-013-2268-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is performed increasingly for pancreatic pathology in the body and tail of the pancreas. However, only few reports have compared its oncological efficacy with open distal pancreatectomy (ODP). We compared these two techniques in patients with pancreatic ductal adenocarcinoma. METHODS From a prospectively maintained database, all patients who underwent either LDP or ODP for adenocarcinoma in the body and tail of the pancreas between January 2008 and December 2011 were compared. Data were analysed using SPSS(®) v19 utilising standard tests. A p value <0.05 was considered significant. RESULTS Of 101 patients who underwent distal pancreatectomy, 22 had histologically confirmed adenocarcinoma (LDP n = 8, ODP n = 14). Both groups were well matched for age and the size of tumour (22 vs. 32 mm, p = 0.22). Intraoperative blood loss was 306 ml compared with 650 ml for ODP (p = 0.152). A longer operative time was noted for LDP (376 vs. 274 min, p < 0.05). Total length of stay was shorter for LDP compared with ODP (8 vs. 12 days, p = 0.05). The number of postoperative pancreatic fistulas were similar (LDP n = 2 vs. ODP n = 3, p = 0.5). Complete resection (R0) was achieved in 88 % of LDP (n = 7) compared with 86 % of ODP (n = 12). The median number of lymph nodes harvested was 16 for LDP versus 14 for ODP. Overall 3-year survival also was similar: LDP = 82 %, ODP = 74 % (p = 0.89). CONCLUSIONS From an oncological perspective, LDP is a viable procedure and its results are comparable to ODP for ductal adenocarcinomas arising in the body and tail of the pancreas.
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Affiliation(s)
- S Rehman
- Department of Hepatobiliary and Transplantation Surgery, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK,
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9
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McGrann PF, Pooleman IJ, Wilson CH, Haugk B, Scott J, Charnley RM. Primary hepatic Ewing's sarcoma with cytogenetic confirmation. J Gastrointest Surg 2014; 18:635-7. [PMID: 23877327 DOI: 10.1007/s11605-013-2284-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 06/16/2013] [Accepted: 07/02/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Extraskeletal Ewing's sarcoma is reported in the medical literature, but none has been described as presenting with a resectable liver mass. METHODS A case of a 29-year-old male patient who presented with a large symptomatic mass in the right lobe of the liver which, following resection, demonstrated the characteristic histopathology and fusion protein (EWSR1-Fli1) found in Ewing's sarcoma was reported. DISCUSSION Complete surgical resection offers the best long-term outlook. Cure rates with appropriate surgical and chemotherapeutic management range between 30 and 60 %.
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Affiliation(s)
- P F McGrann
- Department of Hepatopancreaticobiliary Surgery, The Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, UK, NE7 7DN
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John SKP, Robinson SM, Rehman S, Harrison B, Vallance A, French JJ, Jaques BC, Charnley RM, Manas DM, White SA. Prognostic factors and survival after resection of colorectal liver metastasis in the era of preoperative chemotherapy: an 11-year single-centre study. Dig Surg 2013; 30:293-301. [PMID: 23969407 DOI: 10.1159/000354310] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 07/14/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION A variety of factors have been identified in the literature which influence survival following resection of colorectal liver metastases (CRLM). Much of this literature is historical, and its relevance to contemporary practice is not known. The aim of this study was to identify those factors which influence survival during the era of preoperative chemotherapy in patients undergoing resection of CRLM in a UK centre. METHODS All patients having liver resection for CRLM during an 11-year period up to 2011 were identified from a prospectively maintained database. Prognostic factors analysed included tumour size (≥5 or <5 cm), lymph node status of the primary tumour, margin positivity (R1; <1 mm), neo-adjuvant chemotherapy (for liver), tumour differentiation, number of liver metastases (≥4), preoperative carcinoembryonic antigen (CEA; ≥200 ng/ml) and whether metastases were synchronous (i.e. diagnosed within 12 months of colorectal resection) or metachronous to the primary tumour. Overall survival (OS) was compared using Kaplan-Meier plots and a log rank test for significance. Multivariate analysis was performed using a Cox regression model. Statistical analysis was performed in SPSS v19, and p < 0.05 was considered to be significant. RESULTS 432 patients underwent resection of CRLM during this period (67% male; mean age 64.5 years), and of these, 54 (13.5%) had re-resections. The overall 5-year survival in this series was 43% with an actuarial 10-year survival of 40%. A preoperative CEA ≥200 ng/ml was present in 10% of patients and was associated with a poorer 5-year OS (24 vs. 45%; p < 0.001). A positive resection margin <1 mm was present in 16% of patients, and this had a negative impact on 5-year OS (15 vs. 47%; p < 0.001). Tumour differentiation, number, biliary or vascular invasion, size, relationship to primary disease, nodal status of the primary disease or the use of neo-adjuvant chemotherapy had no impact on OS. Multivariate analysis identified only the presence of a positive resection margin (OR 1.75; p < 0.05) and a preoperative CEA ≥200 ng/ml (OR 1.88; p < 0.01) as independent predictors of poor OS. CONCLUSION Despite the wide variety of prognostic factors reported in the literature, this study was only able to identify a preoperative CEA ≥200 ng/ml and the presence of tumour within 1 mm of the resection margin as being of value in predicting survival. These variables are likely to identify patients who may benefit from intensive follow-up to enable early aggressive treatment of recurrent disease.
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Affiliation(s)
- S K P John
- Department of Hepatobiliary and Transplantation Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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11
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Ausania F, Jackson R, Tsirlis T, Charnley RM. Portal vein occlusion following pancreatico-duodenectomy and portal vein resection: treatment by percutaneous portal vein stent. Ann R Coll Surg Engl 2013. [PMID: 23676819 DOI: 10.1308/003588413x13629960046075c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- F Ausania
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK.
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12
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Ausania F, Jackson R, Tsirlis T, Charnley RM. Portal vein occlusion following pancreaticoduodenectomy and portal vein resection: treatment by percutaneous portal vein stent. Ann R Coll Surg Engl 2013; 95:299-299. [DOI: 10.1308/rcsann.2013.95.4.299] [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: 08/29/2023] Open
Affiliation(s)
- F Ausania
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - R Jackson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - T Tsirlis
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - RM Charnley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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13
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Ausania F, Vallance AE, Manas DM, Prentis JM, Snowden CP, White SA, Charnley RM, French JJ, Jaques BC. Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome. Ann R Coll Surg Engl 2013; 94:563-8. [PMID: 23131226 PMCID: PMC3954282 DOI: 10.1308/003588412x13373405386934] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with high risk of postoperative complications. The aim of this study was to identify pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome. METHODS Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and cardiopulmonary exercise testing (CPET) were collected. RESULTS Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39–79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p=0.005 and p=0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p=0.003, odds ratio: 3.261). CONCLUSIONS P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.
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Affiliation(s)
- F Ausania
- HPB Unit, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne NE7 7DN, UK.
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14
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Ausania F, McDonald S, Kallas K, Charnley RM, White SA. Intravascular stenting to treat left hepatic vein stenosis following extended right hepatectomy. ACTA ACUST UNITED AC 2012; 38:417-8. [PMID: 22955579 DOI: 10.1007/s00261-012-9945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Charnley RM. Effect of specialist decision-making on treatment strategies for colorectal liver metastases (Br J Surg 2012; 99: 1263-1269). Br J Surg 2012; 99:1269-70. [PMID: 22864888 DOI: 10.1002/bjs.8886] [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: 11/07/2022]
Affiliation(s)
- R M Charnley
- Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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16
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Ausania F, Snowden CP, Prentis JM, Holmes LR, Jaques BC, White SA, French JJ, Manas DM, Charnley RM. Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy. Br J Surg 2012; 99:1290-4. [DOI: 10.1002/bjs.8859] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2012] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Postoperative complications are increased in patients with reduced cardiopulmonary reserve undergoing major surgery. Pancreatic leak is an important contributor to postoperative complications and death following pancreaticoduodenectomy. The aim of this study was to determine whether reduced cardiopulmonary reserve was a risk factor for pancreatic leak.
Methods
All patients who underwent pancreaticoduodenectomy between January 2006 and July 2010 were identified from a prospectively held database. Data analysis was restricted to those who underwent cardiopulmonary exercise testing during preoperative assessment. Pancreatic leak was defined as grade A, B or C according to the International Study Group on Pancreatic Fistula definition. An anaerobic threshold (AT) cut-off value of 10·1 ml per kg per min was used to identify patients with reduced cardiopulmonary reserve. Univariable and multivariable analyses were performed to identify other risk factors for pancreatic leak.
Results
Some 67 men and 57 women with a median age of 66 (range 37–82) years were identified. Low AT was significantly associated with pancreatic leak (45 versus 19·2 per cent in patients with greater cardiopulmonary reserve; P = 0·020), postoperative complications (70 versus 38·5 per cent; P = 0·013) and prolonged hospital stay (29·4 versus 17·5 days; P = 0·001). On multivariable analysis, an AT of 10·1 ml per kg per min or less was the only independent factor associated with pancreatic leak.
Conclusion
Low cardiopulmonary reserve was associated with pancreatic leak following pancreaticoduodenectomy. AT seems a useful tool for stratifying the risk of postoperative complications.
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Affiliation(s)
- F Ausania
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - C P Snowden
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - J M Prentis
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - L R Holmes
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - B C Jaques
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - S A White
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - J J French
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - D M Manas
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - R M Charnley
- Hepatopancreatobiliary Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
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17
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Robinson SM, Rahman A, Haugk B, French JJ, Manas DM, Jaques BC, Charnley RM, White SA. Metastatic lymph node ratio as an important prognostic factor in pancreatic ductal adenocarcinoma. Eur J Surg Oncol 2012; 38:333-9. [PMID: 22317758 DOI: 10.1016/j.ejso.2011.12.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [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: 07/05/2011] [Revised: 12/13/2011] [Accepted: 12/19/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND Overall five year survival following pancreaticoduodenectomy for ductal adenocarcinoma is poor with typical reported rates in the literature of 8-27%. The aim of this study was to identify the histological variables best able to predict long-term survival in these patients. METHODS A prospective database of patients undergoing pancreaticoduodenectomy between April 2002 and June 2009 was analysed to identify patients with histologically proven pancreatic ductal adenocarcinoma. Patients with ampullary tumours, cholangiocarcinoma, duodenal adenocarcinoma and neuroendocrine tumours were excluded. The histology reports for these patients were reviewed. Uni-variate and multi-variate survival analysis was performed to identify variables useful in predicting long-term outcome. RESULTS 134 patients underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma during this period. 5 year survival in this series was 18.6%. Uni-variate analysis identified nodal status and the metastatic to resected lymph node ratio as predictors of survival. Using multi-variate Cox Regression analysis a metastatic to lymph node ratio of >15% (p < 0.01) and the presence of perineural invasion (p < 0.05) were identified as independent predictors of patient survival. Metastatic to resected lymph node ratio is better able to stratify prognosis than nodal status alone with 5 year survival of those with N0 disease being 55.6% and 12.9% for N1 disease. However for those with <15% of resected nodes positive, 5 year survival was 21.7% and in those with >15% nodes positive it was 5.2% (p = 0.0017). CONCLUSION The metastatic to resected lymph node ratio can provide significant prognostic information in those patients with node positive disease after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.
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Affiliation(s)
- S M Robinson
- Department of HPB Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.
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18
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Paterson-Brown S, Charnley RM. Authors' reply: Surgeon volumes in oesophagogastric and hepatopancreatobiliary resectional surgery ( Br J Surg 2011; 98: 891–893). Br J Surg 2011. [DOI: 10.1002/bjs.7696] [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: 11/05/2022]
Affiliation(s)
| | - R M Charnley
- Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
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19
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Chatterjee S, Ibrahim B, Charnley RM, Scott J, Nayar M. Endoscopic ultrasound-guided gastroenterostomy for palliative drainage of an obstructed hepaticojejunostomy loop. Endoscopy 2011; 43 Suppl 2 UCTN:E1-2. [PMID: 21240837 DOI: 10.1055/s-0030-1255720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- S Chatterjee
- Department of Gastroenterology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.
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20
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Affiliation(s)
- R M Charnley
- Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
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21
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Jones RT, French JJ, Scott J, Manas DM, Charnley RM. Radiofrequency ablation resulting in left lobe hypertrophy and improved resectability. Case Rep Gastroenterol 2011; 5:132-5. [PMID: 21512619 PMCID: PMC3080585 DOI: 10.1159/000326959] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Surgical resection for colorectal liver metastases may only be considered when an adequate functional residual volume can be preserved. Selective portal venous embolisation may be used to increase this volume, whilst chemotherapy and radiofrequency ablation (RFA) can be used to treat inoperable lesions. A 73-year-old man with liver metastasis proceeded to surgery, with the intention to perform a right hemi-hepatectomy. Unexpectedly at laparotomy, despite adequate pre-operative imaging, both the right and middle hepatic veins were involved. At that time extended right hemi-hepatectomy was contraindicated by insufficient residual volume and RFA was performed. Follow-up imaging revealed atrophy of the lesion. Significantly, there was also left lateral lobe hypertrophy sufficient to permit resection, which was performed without complication. Thrombosis of intra-hepatic portal veins is a recognised complication of RFA but here it appears to have been beneficial. The case highlights the need for regular review of unresectable hepatic disease by a liver surgeon and could suggest new modalities of portal embolisation.
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Affiliation(s)
- R T Jones
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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22
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Oppong KW, Richardson DL, Charnley RM, Nayar MK. The development and evolution of a tertiary pancreaticobiliary endoscopic ultrasound service: lessons learned. Frontline Gastroenterol 2011; 2:66-70. [PMID: 28839586 PMCID: PMC5517212 DOI: 10.1136/fg.2010.003814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2010] [Indexed: 02/04/2023] Open
Abstract
This article reviews the development of the hepatopancreatobiliary (HPB) endoscopic ultrasound (EUS) service at Freeman Hospital and seeks to identify from our experience learning points for good practice and pitfalls to avoid. The Freeman HPB EUS service has expanded rapidly over the past 10 years in response to the consolidation of cancer care and aligned to the needs of the cancer network. Effective multidisciplinary teamwork and increased subspecialisation by the endosonographers has allowed the efficient use of capacity and development of skills. Mechanisms for monitoring diagnostic performance put in place at the outset of the EUS-fine needle aspiration programme have helped to identify interventions that have led to improved test performance. An excellent working relationship between all stakeholders is critical to the success of such a service as is a preparedness to seek and respond to the views of patients and referrers.
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Affiliation(s)
- K W Oppong
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - D L Richardson
- Department of Diagnostic Imaging, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - R M Charnley
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK,Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - M K Nayar
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK,Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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23
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Imrie CW, Connett G, Hall RI, Charnley RM. Review article: enzyme supplementation in cystic fibrosis, chronic pancreatitis, pancreatic and periampullary cancer. Aliment Pharmacol Ther 2010; 32 Suppl 1:1-25. [PMID: 21054452 DOI: 10.1111/j.1365-2036.2010.04437.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Over 11000 UK patients each year develop pancreatic exocrine insufficiency--the major causes are not rare: cystic fibrosis (>300 new cases/year), pancreatic cancer (>7000 new cases/year) and chronic pancreatitis (>4000 new cases/year). Affected patients present in diverse ways, and for chronic pancreatitis, diagnosis is frequently made rather late in the course of the disease. AIM To raise awareness of key clinical issues specific to patients with pancreatic exocrine insufficiency through experience from UK clinicians, and to offer advice regarding appropriate treatment with pancreatic enzymes. METHODS Three case studies describe clinical issues relating to pancreatic enzyme supplementation that may lead to underuse in patients with cystic fibrosis, pancreatic and periampullary cancer or chronic pancreatitis. RESULTS The efficacy of the treatment of exocrine pancreatic insufficiency is dependent on adequate meal-time enzyme replacement therapy. Improvements in patients' weight and nutritional status are what is aimed for - an important reason for all doctors, nurses and dieticians to give this therapy close attention. CONCLUSIONS Pancreatic exocrine insufficiency may result in malnutrition, but enzyme supplementation can greatly improve quality of life in these patients.
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Affiliation(s)
- C W Imrie
- Lister Department of Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK.
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24
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Sewpaul A, French JJ, Khoo TK, Kernohan M, Kirby JA, Charnley RM. Soluble E-cadherin: an early marker of severity in acute pancreatitis. HPB Surg 2009; 2009:397375. [PMID: 19421334 PMCID: PMC2674558 DOI: 10.1155/2009/397375] [Citation(s) in RCA: 15] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/18/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS At present, there is no simple test for predicting severity in acute pancreatitis. We investigated the use of an assay of soluble E-cadherin (sE-cadherin). METHODS Concentrations of sE-cadherin, from 19 patients with mild acute pancreatitis, 7 patients with severe acute pancreatitis, 11 patients with other acute gastrointestinal pathologies, and 12 healthy subjects were measured using a commercially available sandwich ELISA kit based on two monoclonal antibodies specific to the extracellular fragment of human E-cadherin. Measurements were made at 12 hours or less from onset of pain and also at 24 and 48 hours after onset of pain. RESULTS Mean (standard deviation) concentration of sE-cadherin in patients with severe acute pancreatitis at <12 hours was 17780 ng/mL (7853), significantly higher than that of healthy volunteers 5180 ng/mL (1350), P = .0039, patients with other gastrointestinal pathologies 7358 ng/mL (6655), P = .0073, and also significantly higher than that of patients with mild pancreatitis, 7332 ng/mL (2843), P = .0019. DISCUSSION Serum sE-cadherin could be an early (within 12 hours) objective marker of severity in acute pancreatitis. This molecule warrants further investigation in the form of a large multicentre trial.
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Affiliation(s)
- A. Sewpaul
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - J. J. French
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - T. K. Khoo
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - M. Kernohan
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - J. A. Kirby
- Department of Surgery, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, UK
| | - R. M. Charnley
- HPB Surgical Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
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25
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Lochan R, Sen G, Barrett AM, Scott J, Charnley RM. Management strategies in isolated pancreatic trauma. ACTA ACUST UNITED AC 2009; 16:189-96. [PMID: 19214372 DOI: 10.1007/s00534-009-0042-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Accepted: 04/03/2008] [Indexed: 12/26/2022]
Abstract
AIM In the absence of damage to other organs, pancreatic injury is rare. We have reviewed our experience with isolated pancreatic injury. METHODS Patients treated for isolated pancreatic trauma at our unit were identified prospectively and then retrospectively entered onto a database. The mode of presentation, mechanism of injury and management strategies were reviewed. RESULTS Seven male and four female patients, median age 30 years (range 13-51 years) were treated. All suffered blunt abdominal trauma with different mechanisms of injury, each being characterised by a direct blow to the central abdomen. In two patients, somatostatin analogue treatment used as primary treatment resulted in early resolution of symptoms and signs. Six patients underwent surgery at various stages post-injury. At a median follow-up of 58 months (range 22-106 months), eight patients are asymptomatic, two patients have chronic pain following distal pancreatectomy and one patient has occasional discomfort. CONCLUSION Confirmation of the mechanism of trauma and suspicion of pancreatic injury are essential for early diagnosis and appropriate management. Early contrast computed tomography examination is vital in the recognition of these injuries. Somatostatin analogue therapy may have an important role in the treatment regimen, especially when patients present early after sustaining a pancreatic injury. Only selected patients require open surgery.
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Affiliation(s)
- R Lochan
- Department of Surgery, Hepato-Pancreato-Biliary Surgery Unit, Freeman Hospital, Newcastle upon Tyne, UK
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26
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French JJ, Mansfield SD, Jaques K, Jaques BC, Manas DM, Charnley RM. Fast-track management of patients undergoing proximal pancreatic resection. Ann R Coll Surg Engl 2009; 91:201-4. [PMID: 19220943 DOI: 10.1308/003588409x391893] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy. PATIENTS AND METHODS Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months. RESULTS Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 micromol/l (81.6) at the time of the operation compared to 43 micromol/l (51.3; P > or = 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P < or = 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged. CONCLUSIONS Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.
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Affiliation(s)
- J J French
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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27
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Abstract
BACKGROUND A comprehensive epidemiological study of acute pancreatitis (AP) using reliable objective methods of patient identification with the inclusion of socioeconomic factors has not been reported previously. METHODS The study included all patients with AP identified by raised serum amylase or lipase levels admitted to 18 hospitals over 6 months. Clinical records were reviewed to confirm the diagnosis, aetiology and outcome. Patients were stratified into quintiles of socioeconomic deprivation. Age-standardized incidence (ASI) and mortality were calculated. RESULTS Clinical data were reviewed for all 963 identified patients. The ASI was 56.5 per 10(5) per annum, double the highest figure reported previously in the UK. Univariable logistic regression analysis showed a high ASI among older age groups (odds ratio (OR) 1.06 per year; P < 0.001) and in areas of high deprivation (OR 2.40 between least and most deprived; P < 0.001); the latter was predominantly related to alcoholic aetiology (OR 6.50 (95 per cent confidence interval 3.90 to 10.84)). CONCLUSION The incidence of AP based on a highly sensitive method of case identification was higher than previously reported. A clear relationship was found between socioeconomic deprivation and incidence of AP, which was largely explained by a higher incidence of alcoholic aetiology.
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Affiliation(s)
- M P Ellis
- Medical School, University of Newcastle upon Tyne, UK
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28
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Mansfield SD, Scott J, Oppong K, Richardson DL, Sen G, Jaques BC, Manas DM, Charnley RM. Comparison of multislice computed tomography and endoscopic ultrasonography with operative and histological findings in suspected pancreatic and periampullary malignancy. Br J Surg 2008; 95:1512-20. [PMID: 18942059 DOI: 10.1002/bjs.6330] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND This study compared multislice computed tomography (MSCT) with endoscopic ultrasonography (EUS) in the diagnosis and staging of pancreatic and periampullary malignancy. METHODS Data were collected prospectively on patients having MSCT and EUS for suspected pancreatic and periampullary malignancy. RESULTS Eighty-four patients had MSCT and EUS, of whom 35 underwent operative assessment (29 resections). In assessing malignancy, there was no significant difference between MSCT and EUS, and agreement was good (82 per cent, kappa = 0.49); the sensitivity and specificity of MSCT were 97 and 87 per cent, compared with 95 and 52 per cent respectively for EUS (P = 0.264). For portal vein/superior mesenteric vein invasion, MSCT was superior (P = 0.017) and agreement was moderate (72 per cent, kappa = 0.42); the sensitivity and specificity were 88 and 92 per cent for MSCT, and 50 and 83 per cent for EUS. For resectability, there was no significant difference and agreement was good (78 per cent, kappa = 0.51). EUS had an impact on the management of 14 patients in whom MSCT suggested benign disease or equivocal resectability. CONCLUSION MSCT is the imaging method of choice for pancreatic and periampullary tumours. Routine EUS should be reserved for those with borderline resectability on MSCT.
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Affiliation(s)
- S D Mansfield
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
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29
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Abstract
BACKGROUND The strongest risk factors for pancreatic adenocarcinoma are tobacco smoking and increasing age. However, only a few smokers or elderly individuals develop the disease and genetic factors are also likely to be important. METHODS The literature on genetic factors modifying susceptibility to cancer was reviewed, with particular regard to the interindividual variation that exists in the development of pancreatic adenocarcinoma. RESULTS Tobacco-derived carcinogen-metabolizing enzyme gene variants have been the main area of study in stratifying the risk of sporadic pancreatic cancer. Inconsistent results have emerged from the few molecular epidemiological studies performed. CONCLUSION There is great scope for further investigation of critical pathways and unidentified genetic influences may be revealed. This may eventually allow the identification of individuals at high risk who might be targeted for screening.
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Affiliation(s)
- R Lochan
- Hepato-Pancreato-Biliary Unit, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
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30
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Abstract
BACKGROUND AND STUDY AIMS Open pancreatic necrosectomy is the standard treatment for infected pancreatic necrosis but is associated with significant morbidity, mortality, and prolonged hospital stay. Percutaneous or endoscopic necrosectomy are alternative techniques. We evaluated the use of endoscopic necrosectomy for treatment of patients with necrosis that could be accessed through the posterior wall of the stomach. PATIENTS AND METHODS We retrospectively analyzed the indication, patient status according to acute physiology and chronic health evaluation (APACHE) 2 severity score, and success of endoscopic necrosectomy as primary treatment, in selected patients with localized infected pancreatic necrosis, who presented between May 2002 and October 2004. After the necrosis cavity had been accessed, with the assistance of endoscopic ultrasound, a large orifice was created and necrotic debris was removed using endoscopic accessories under radiological control. Follow-up was clinical and radiological. RESULTS 13 patients (nine men, four women, mean age 53 years), 11 with positive bacteriology, underwent attempted endoscopic necrosectomy. Median APACHE 2 score on presentation was 8 (range 1-18). Four patients needed intensive therapy unit care and one other patient required (nonventilatory) high-dependency unit care only. Necrosis was successfully treated endoscopically in 12 patients, requiring a mean of 4 endoscopic interventions (range 1-10); one patient required open surgery; two underwent additional percutaneous necrosectomy and one required laparoscopic drainage. Two patients died of complications unrelated to the procedure. The 11 survivors have a median (range) follow-up of 16 (6-38) months. CONCLUSION Endoscopic necrosectomy is a safe method for treatment of infected pancreatic necrosis. Multiple procedures are usually needed. It may be combined with other methods of surgical intervention. Larger prospective studies will more precisely define its role.
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Affiliation(s)
- R M Charnley
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK.
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Mansfield SD, Barakat O, Charnley RM, Jaques BC, O'Suilleabhain CB, Atherton PJ, Manas D. Management of hilar cholangiocarcinoma in the North of England: pathology, treatment, and outcome. World J Gastroenterol 2006; 11:7625-30. [PMID: 16437689 PMCID: PMC4723393 DOI: 10.3748/wjg.v11.i48.7625] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the management and outcome of hilar cholangiocarcinoma (Klatskin tumor) in a single tertiary referral center. METHODS The notes of all patients with a diagnosis of hilar cholangiocarcinoma referred to our unit for over an 8-year period were identified and retrospectively reviewed. Presentation, management and outcome were assessed. RESULTS Seventy-five patients were identified. The median age was 64 years (range 34-84 years). Male to female ratio was 1:1. Eighty-nine percent of patients presented with jaundice. Most patients referred were under Bismuth classification 3a, 3b or 4. Seventy patients required biliary drainage, 65 patients required 152 percutaneous drainage procedures, and 25 had other complications. Forty-one patients had 51 endoscopic drainage procedures performed (15 failed). Of these, 36 subsequently required percutaneous drainage. The median number of drainage procedures for all patients was three, 18 patients underwent resection (24%), nine had major complications and three died post-operatively. The 5-year survival rate was 4.2% for all patients, 21% for resected patients and 0% for those who did not undergo resection (P = 0.0021). The median number of admissions after diagnosis in resected patients was two and three in non-resected patients (P<0.05). Twelve patients had external-beam radiotherapy, seven brachytherapy, and eight chemotherapy. There was no significant benefit in terms of survival (P = 0.46) or hospital admissions. CONCLUSION Resection increases survival but carries the risk of significant morbidity and mortality. Percutaneous biliary drainage is almost always necessary and endoscopic drainage should be avoided if possible.
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Affiliation(s)
- S D Mansfield
- Hepato-Pancreatico-Biliary Surgery Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne, Tyne and Wear NE7 7DN, United Kingdom.
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Mansfield SD, Sen G, Oppong K, Jacques BC, O'Suilleabhain CB, Manas DM, Charnley RM. Increase in serum bilirubin levels in obstructive jaundice secondary to pancreatic and periampullary malignancy--implications for timing of resectional surgery and use of biliary drainage. HPB (Oxford) 2006; 8:442-5. [PMID: 18333099 PMCID: PMC2020762 DOI: 10.1080/13651820600919860] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Routine preoperative biliary drainage in cases of jaundice secondary to pancreatobiliary malignancy is associated with a significant risk of complications, failure and stent occlusion. It may be possible to avoid biliary drainage in those patients who are not deeply jaundiced. AIMS To measure presenting serum bilirubin and its rate of increase in patients with malignant obstructive jaundice. To predict the urgency with which surgery should be performed to avoid preoperative biliary drainage. PATIENTS AND METHODS Prospective data collection for all pancreatic and periampullary malignancies over a period of 18 months was carried out. Serum bilirubin levels before successful drainage were recorded. Rates of increase in bilirubin and the number of days for bilirubin to reach different thresholds were calculated. RESULTS Of 111 patients, 66 (59%) had resectable disease on imaging investigations. Median serum bilirubin on presentation was 160 micromol/l. Median increase was 13.1 micromol/l/day or approximately 100 micromol/l/week. The predicted number of days for bilirubin levels to reach a variety of thresholds varied significantly. For a patient presenting with a serum bilirubin of 160 micromol/l, the mean number of days for it to rise to 200 micromol/l, 300 micromol/l, 400 micromol/l and 500 micromol/l was 3, 13, 22 and 31 days, respectively. CONCLUSIONS There is a variable window of opportunity in jaundiced patients with pancreatic and periampullary malignancy during which surgery may be performed to avoid biliary drainage procedures, depending on the threshold for operating on the jaundiced patient.
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Affiliation(s)
- S. D. Mansfield
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
| | - G. Sen
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
| | - K. Oppong
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
| | - B. C. Jacques
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
| | | | - D. M. Manas
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
| | - R. M. Charnley
- Hepato-Pancreato-Biliary Unit, Freeman HospitalNewcastle-upon-TyneUK
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Charnley RM, Lau WY, Tate JJT, Kwok S, Li AKC, Eu KW, Milsom JW, Lau WY, Tate JJT, Kwok S, Li AKC. Prospective comparison of laparoscopic and conventional anterior resection. Br J Surg 2005. [DOI: 10.1002/bjs.1800810548] [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: 11/05/2022]
Affiliation(s)
- R M Charnley
- Department of Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - W Y Lau
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - J J T Tate
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - S Kwok
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - A K C Li
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - K-W Eu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44 195, USA
| | - J W Milsom
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44 195, USA
| | - W Y Lau
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - J J T Tate
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - S Kwok
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - A K C Li
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Affiliation(s)
- R M Charnley
- University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - D L Morris
- University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Abstract
Matrix metalloproteinases (MMPs) are implicated in tumour invasion and metastasis. We report the first use of an MMP inhibitor to treat unresectable cholangiocarcinoma. Four men with stage IV cholangiocarcinoma received oral Marimastat (10 mg bd) indefinitely following relief of obstructive jaundice. Monthly measurements of the tumour marker CA 19-9 were used as an indicator of disease response and activity. CA 19-9 levels dropped sharply and stayed low in the two patients who appeared to respond. Mean survival of the four patients was 21.5 months (range 4-48 months). Side effects were well tolerated. A more extensive and detailed examination of MMP inhibitors to treat cholangiocarcinoma is indicated.
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Affiliation(s)
- J. J French
- Hepato-Pancreato-Biliary Surgical UnitPortsmouthUK
| | | | - M. K. Bennett
- Department of Histopathology, Freeman HospitalNewcastle upon Tyne
| | - D. M. Manas
- Hepato-Pancreato-Biliary Surgical UnitPortsmouthUK
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Lynn S, Borthwick GM, Charnley RM, Walker M, Turnbull DM. Heteroplasmic ratio of the A3243G mitochondrial DNA mutation in single pancreatic beta cells. Diabetologia 2003; 46:296-9. [PMID: 12627331 DOI: 10.1007/s00125-002-1018-z] [Citation(s) in RCA: 41] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2002] [Accepted: 08/23/2002] [Indexed: 11/27/2022]
Abstract
AIMS/HYPOTHESIS To examine whether there is a high content of mutated mitochondrial DNA in individual pancreatic beta cells from a patient with the A3243G mitochondrial DNA mutation. METHODS Tissues were available from a patient with diabetes and the A3243G mutation including pancreatic tissue. We quantified the amount of mutated mitochondrial DNA in tissue homogenates and single pancreatic beta cells using hot last cycle PCR. RESULTS The percentage ratio of mutated to wild-type mtDNA was high in tissues such as muscle and brain (>60%), but surprisingly low in both pancreatic islets and in individual beta cells from these islets. The islets were smaller in the patient than in control subjects in keeping with a decreased beta-cell mass. CONCLUSIONS/INTERPRETATION These observations suggest that either the beta cells show increased sensitivity to the effects mtDNA mutations on respiratory chain function, and/or cells with a high mutant load are preferentially removed leading to a progressive decrease in the islet beta-cell mass.
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Affiliation(s)
- S Lynn
- Department of Medicine, The Medical School, University of Newcastle upon Tyne, Framlington Place, NE2 4HH Newcastle upon Tyne, United Kingdom
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Creighton JE, Lyall R, Wilson DI, Curtis A, Charnley RM. Prevalence of R117H mutation in the cationic trypsinogen gene in patients with hereditary pancreatitis. Br J Surg 2003. [DOI: 10.1046/j.1365-2168.1999.1062b.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
The R117H mutation of the cationic trypsinogen (CT) gene (G to A mutation in exon 3), located on chromosome 7q35, is one of the known mutations that is linked to hereditary pancreatitis (HP) and is thought to alter a trypsin recognition site responsible for the breakdown of inappropriately activated trypsinogen so resulting in pancreatitis. The aim of this study was to determine the prevalence of this mutation in patients with HP and to correlate presence of the mutation with disease characteristics.
Methods
Polymerase chain reaction amplification of the third exon of the CT gene was performed on blood DNA. This was digested by the restriction endonuclease Afl III and fragments were sized by agarose gel electrophoresis. Haplotype analysis was carried out using three short tandem repeat markers in the region of the CT gene.
Results
Seven discrete families with HP (three to seven generations) were identified (22 affected individuals). The mutation was present in individuals from three of the seven families. It was absent in all affected individuals from the other four families. A higher proportion of patients requiring pancreatic surgery was seen in families expressing this mutation (eight of 14 versus one of eight, P = 0·016). Mean(s.d.) age of onset was similar in both groups (7·9(5·8) versus 6·3(10·1) years, P = 0·13). In the affected families, the same high-risk haplotype was present in two families, suggesting a common ancestor. The third family carried a unique haplotype.
Conclusion
A single G to A mutation in the third exon of the CT gene was found in three families with HP originating from this region and appears to be associated with more severe disease. Further work is being undertaken to analyse the CT gene more fully in families in which this common first mutation was not identified.
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Affiliation(s)
- J E Creighton
- Department of Hepato-Pancreatico-Biliary Surgery, Freeman Hospital, Northern Region Genetics Service, Newcastle upon Tyne, UK
| | - R Lyall
- Department of Human Genetics, Northern Region Genetics Service, Newcastle upon Tyne, UK
| | - D I Wilson
- Department of Human Genetics, Northern Region Genetics Service, Newcastle upon Tyne, UK
| | - A Curtis
- Department of Human Genetics, Northern Region Genetics Service, Newcastle upon Tyne, UK
| | - R M Charnley
- Department of Hepato-Pancreatico-Biliary Surgery, Freeman Hospital, Northern Region Genetics Service, Newcastle upon Tyne, UK
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Abstract
BACKGROUND Biliary obstruction in chronic pancreatitis may be relieved by the insertion of a biliary endoprosthesis. Stenting is usually achieved with a plastic device, but self-expandable metal stents may also be used. CASE OUTLINES Two patients are described with severe chronic pancreatitis complicated by biliary obstruction and portal vein thrombosis, who underwent insertion of metallic biliary endoprostheses. In both patients the endoprostheses became occluded, at 12 and 7 months respectively, which necessitated open operation. Both patients experienced surgical complications and one patient died postoperatively. DISCUSSION The use of metal endoprostheses in chronic pancreatitis may result in occlusion, necessitating open operation. Such stents should be used with caution in these patients, who are likely to be high-risk surgical candidates.
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Affiliation(s)
- JJ French
- Hepato-Pancreato-Biliary Surgical Unit, Freeman HospitalNewcastle upon TyneUK
| | - RM Charnley
- Hepato-Pancreato-Biliary Surgical Unit, Freeman HospitalNewcastle upon TyneUK
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French JJ, Cresswell J, Wong WK, Seymour K, Charnley RM, Kirby JA. T cell adhesion and cytolysis of pancreatic cancer cells: a role for E-cadherin in immunotherapy? Br J Cancer 2002; 87:1034-41. [PMID: 12434297 PMCID: PMC2364324 DOI: 10.1038/sj.bjc.6600597] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2002] [Revised: 08/19/2002] [Accepted: 08/22/2002] [Indexed: 11/09/2022] Open
Abstract
Pancreatic cancer is an aggressive and potent disease, which is largely resistant to conventional forms of treatment. However, the discovery of antigens associated with pancreatic cancer cells has recently suggested the possibility that immunotherapy might become a specific and effective therapeutic option. T cells within many epithelia, including those of the pancreas, are known to express the alphaEbeta7-integrin adhesion molecule, CD103. The only characterised ligand for CD103 is E-cadherin, an epithelial adhesion molecule which exhibits reduced expression in pancreatic cancer. In our study, CD103 was found to be expressed only by activated T cells following exposure to tumour necrosis factor beta 1, a factor produced by many cancer cells. Significantly, the expression of this integrin was restricted mainly to class I major histocompatibility complex-restricted CD8+ T cells. The human pancreatic cancer cell line Panc-1 was transfected with human E-cadherin in order to generate E-cadherin negative (wild type) and positive (transfected) sub-lines. Using a sensitive flow cytometric adhesion assay it was found that the expression of both CD103 (on T cells) and E-cadherin (on cancer cells) was essential for efficient adhesion of activated T cells to pancreatic cancer cells. This adhesion process was inhibited by the addition of antibodies specific for CD103, thereby demonstrating the importance of the CD103-->E-cadherin interaction for T-cell adhesion. Using a 51Cr-release cytotoxicity assay it was found that CD103 expressing T cells lysed E-cadherin expressing Panc-1 target cells following T cell receptor stimulation; addition of antibodies specific for CD103 significantly reduced this lysis. Furthermore, absence of either CD103 from the T cells or E-cadherin expression from the cancer cells resulted in a significant reduction in cancer cell lysis. Therefore, potentially antigenic pancreatic cancer cells could evade a local anti-cancer immune response in vivo as a consequence of their loss of E-cadherin expression; this phenotypic change may also favour metastasis by reducing homotypic adhesion between adjacent cancer cells. We conclude that effective immunotherapy is likely to require upregulation of E-cadherin expression by pancreatic cancer cells or the development of cytotoxic immune cells that are less dependent on this adhesion molecule for efficient effecter function.
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Affiliation(s)
- J J French
- Applied Immunobiology Group, Department of Surgery, The Medical School, University of Newcastle, NE2 4HH, UK
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40
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Seymour K, Charnley RM, Rose JDG, Baudouin CJ, Manas D. Preoperative portal vein embolisation for primary and metastatic liver tumours: volume effects, efficacy, complications and short-term outcome. HPB (Oxford) 2002; 4:21-8. [PMID: 18333148 PMCID: PMC2023908 DOI: 10.1080/136518202753598690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of portal vein embolisation is to induce hyperplasia of normal tissue when resection of a cancerous portion of the liver is contraindicated only by the volume of liver that would remain following operation. METHODS Eight patients with inoperable liver tumours (3 women and 5 men, median age 69.5 years, 3 colorectal hepatic metastasts, 2 choloangiocarcinomas and 3 hepatocellular cancers) were selected for portal vein embolisation. Selected portal branches were occluded with microparticles and coils. Liver volumes were determined by magnetic resonance imaging (MRI) before embolisation and again before operation. RESULTS Embolisation was successfully performed in all 8 patients, 7 by the percutaneous-transhepatic route, while one patient required open cannulation of a mesenteric vein. Management was altered in 6 patients who proceded to 'curative' resection; projected remaining liver volumes increased (Wilcoxon's matched pairs test p=0.02) from a median of 361 cc to a median of 550 cc; two patients had disease progression such that operation was no longer indicated. In one patient a misplaced coil unintentionally occluded a portal branch to normal liver. CONCLUSIONS Portal vein embolisation produced appreciable hyperplasia of the normal liver and extended the option of 'curative' operation to 6 out of the 8 cases attempted. Complications can occur. The long-term results following operation are unknown.
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Affiliation(s)
- K Seymour
- HPB Surgery Unit and Department of Radiology, Freeman HospitalHigh Heaton, Newcastle upon TyneNE7 7DN
| | - RM Charnley
- HPB Surgery Unit and Department of Radiology, Freeman HospitalHigh Heaton, Newcastle upon TyneNE7 7DN
| | - JDG Rose
- HPB Surgery Unit and Department of Radiology, Freeman HospitalHigh Heaton, Newcastle upon TyneNE7 7DN
| | - CJ Baudouin
- HPB Surgery Unit and Department of Radiology, Freeman HospitalHigh Heaton, Newcastle upon TyneNE7 7DN
| | - D Manas
- HPB Surgery Unit and Department of Radiology, Freeman HospitalHigh Heaton, Newcastle upon TyneNE7 7DN
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41
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Abstract
BACKGROUND Free tumour cells in the peritoneal cavity of patients with pancreatic carcinoma carry a poor prognosis. Reactive or degenerative mesothelial cells can make cytological interpretation with conventional stains difficult. Detection of the tumour-associated antigens carcinoembryonic antigen (CEA) and CA19-9 may improve detection. METHODS At staging laparoscopy, 22 patients with pancreatic or periampullary tumours had ascitic fluid aspirated or peritoneal lavage performed. Both conventional and immunocytologically stained preparations were examined. Antibodies to CEA and CA19-9 and the epithelial marker BerEP4 were used. Lavage fluid from ten patients having operative treatment for benign pancreatic or biliary conditions was also examined. RESULTS No malignant cells on conventional cytological criteria were recovered.Thirteen of the 22 patients with pancreatic or periampullary carcinoma had peritoneal cells that were positive for CEA and/or CA19-9. None was positive for BerEP4. No patients with resectable disease had cells that were positive for CEA or CA19-9 compared with 13 of 18 (72%) who had unresectable disease. One patient (10%) with benign disease (chronic pancreatitis) had cells recovered that were weakly positive for CEA but negative for CA19-9 and BerEP4. DISCUSSION Recovery of cells from the peritoneal cavity of patients with pancreatic or periampullary carcinoma that are expressing the tumour-associated antigens CEA or CA19-9 does not indicate the presence of free tumour cells but is associated with advanced disease.
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Affiliation(s)
| | - A Watson
- HPB Surgery Unit, Freeman Hospital
| | - V Wadehra
- Department of Cytology, Royal Victoria InfirmaryNewcastle upon TyneUK
| | - RM Charnley
- Department of Cytology, Royal Victoria InfirmaryNewcastle upon TyneUK
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Abstract
AIMS: The aim of ipsilateral portal vein embolization is to induce hypertrophy of normal tissue when resection of a cancerous portion of the liver is contraindicated only by the volume of liver that would remain following surgery. This study reports its use in primary and metastatic liver tumours. METHODS: Eight patients with inoperable liver tumours (three women and five men of median age 68. 5 years; three colorectal hepatic metastases, two cholangiocarcinomas and three hepatocellular cancers) were selected for portal vein embolization. Selected portal branches were occluded distally with microbeads and proximally with coils. Liver volumes were determined by magnetic resonance imaging before embolization and again before surgery, 6-8 weeks later. RESULTS: Embolization was performed successfully in seven patients by the percutaneous-transhepatic route; one further patient required an open cannulation of the inferior mesenteric vein. Management was altered in six patients, who proceeded to 'curative' surgery. The projected remaining (predominantly left lobe) liver volumes increased significantly from a median of 350 to 550 ml (P < 0.05, Wilcoxon matched pairs test). Two patients had disease progression such that surgery was no longer indicated. One patient, whose disease progressed, had the left portal branch occluded unintentionally by a misplaced coil that was successfully retrieved, although the left portal branch remained occluded. CONCLUSIONS: Portal vein embolization produced significant hypertrophy of the normal liver and extended the option of 'curative' surgery to six of the eight patients in whom it was attempted. It appears to be equally effective for primary and metastatic liver tumours in selected patients.
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Affiliation(s)
- K Seymour
- Hepatobiliary Surgery Unit and Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
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43
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Abstract
BACKGROUND Hereditary pancreatitis has been shown to be caused by one of two mutations (R117H and N21I) of the cationic trypsinogen gene (PRSS1). Families with hereditary pancreatitis in the north of England were investigated for these mutations. The clinical features associated with each mutation were compared. METHODS In individuals from nine families with hereditary pancreatitis, DNA was screened for the R117H and N21I mutations. All five exons of the cationic trypsinogen gene were also sequenced to search for additional mutations. Haplotype analysis was carried out to identify common ancestors. Clinical data were collected. RESULTS The R117H mutation was identified in three families and N21I in a further five. The R117H mutation was associated with a more severe phenotype than N21I in terms of mean(s.d.) age of onset of symptoms (8.4(7.2) versus 16. 5(7.1) years; P = 0.007) and requirement for surgical intervention (eight of 12 versus four of 17 patients respectively; P = 0.029). Haplotype analysis suggested that each mutation had arisen more than once. CONCLUSION Two mutations in the cationic trypsinogen gene cause hereditary pancreatitis in eight of nine families originating in this region. The R117H mutation is associated with a more severe form of the disease in terms of age at onset of symptoms and requirement for surgical intervention.
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Affiliation(s)
- J E Creighton
- Hepatopancreaticobiliary Surgery Unit, Freeman Hospital, Newcastle-upon-Tyne, UK
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44
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Abstract
Metastasis and the processes underlying this phenomenon make epithelial cancers so malignant. Local control of cancers by surgery is sometimes possible but locoregional and distant recurrence commonly lead to the failure of treatment with ensuing morbidity and mortality. Tumour cells express a range of new antigens during growth and there are opportunities for the host immune system to interact with these antigens. This immune interaction eliminates the tumour or allows selection of phenotypic variants. Cell phenotypes selected by an incomplete immune response resemble the cell type commonly associated with metastases. Thus we propose that the host immune system may be responsible for selection of this phenotype and progression of the disease.
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Affiliation(s)
- K Seymour
- School of Surgical and Reproductive Sciences, Medical School, University of Newcastle upon Tyne, Framlington Place, UK.
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45
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Seymour K, Manas D, Charnley RM. During liver regeneration following right portal vein embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma. Br J Surg 1999; 86:1482-3. [PMID: 10617363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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46
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Abstract
BACKGROUND It has been hypothesized that the cirrhotic liver is afforded protection against metastasis. The evidence has been examined and the plausibility of such a phenomenon is reviewed. METHODS A systematic literature review was conducted with analysis of combined data from post-mortem case-control studies. RESULTS Overall, the crude rate of metastasis to normal liver was 37.3 per cent, while the rate to cirrhotic liver was 23.7 per cent. The Mantel-Haenszel (MH) fixed-effects estimate of the odds ratio was 0. 47 (95 per cent confidence interval (c.i.) 0.41-0.53; chi2 = 136, 11 d.f., P < 0.001). The DerSimonian-Laird (DL) random-effects estimation of the odds ratio was 0.42 (95 per cent c.i. 0.31-0.58; chi2 = 28, 1 d.f., P < 0.001). For tumours arising within the distribution of the portal vein, the crude rate of metastasis to normal liver was 47.6 per cent, whereas the rate to cirrhotic liver was 29.8 per cent. The MH estimate of the odds ratio was 0.45 (95 per cent c.i. 0.37-0.54; chi2 = 68.2, 5 d.f., P < 0.001). The DL pooled odds ratio was 0.44 (95 per cent c.i. 0.28-0.70; chi2 = 12.3, 1 d.f., P < 0.001). The MH and DL pooled estimates of the odds ratio were similar for groups of patients from the East (Japan) and the West (Europe and the USA). CONCLUSION The post-mortem evidence reviewed suggests that the likelihood of metastasis to the cirrhotic liver is lower than that to normal liver. The degree of protection for tumours arising from within the distribution of the portal vein is neither greater nor less than it is overall. Eastern and Western populations appear to have a similar degree of risk reduction. The differences noted were significant on testing in the meta-analysis, but confounding bias accounting for these differences has not been excluded.
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Affiliation(s)
- K Seymour
- Department of Surgery, University of Newcastle, Newcastle upon Tyne, UK
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47
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Midwinter MJ, Beveridge CJ, Wilsdon JB, Bennett MK, Baudouin CJ, Charnley RM. Correlation between spiral computed tomography, endoscopic ultrasonography and findings at operation in pancreatic and ampullary tumours. Br J Surg 1999; 86:189-93. [PMID: 10100785 DOI: 10.1046/j.1365-2168.1999.01042.x] [Citation(s) in RCA: 194] [Impact Index Per Article: 7.8] [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: 11/20/2022]
Abstract
BACKGROUND Spiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear. METHODS Forty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings. RESULTS The final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery. CONCLUSION EUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.
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Affiliation(s)
- M J Midwinter
- Hepato-Pancreato-Biliary Surgery Unit, Freeman Hospital, Newcastle upon Tyne, UK
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48
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Midwinter MJ, Charnley RM. Accuracy of laparoscopic ultrasonography in the staging of upper gastrointestinal malignancy. Br J Surg 1997; 84:580. [PMID: 9112924 DOI: 10.1002/bjs.1800840442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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49
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Abstract
Abstract
Surgical x-ray meetings attended by surgeons and radiologists are used for the clarification of x-ray reports and education of those present. Although the value of these meetings is generally accepted in terms of education, it is not known in what way they contribute to patient management. An audit of the authors' weekly surgical x-ray meeting to determine whether such reports and management decisions are modified following review and whether this is of benefit to patients is described.
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Affiliation(s)
- R M Charnley
- Department of Surgery, University Hospital, Nottingham, UK
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50
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Charnley RM, Banerjee AK, Whitaker SC, Spiller RC, Doran J. Peritoneal seeding of pancreatic cancer following transperitoneal biliary procedures. Br J Surg 1995; 82:393. [PMID: 7796020 DOI: 10.1002/bjs.1800820336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- R M Charnley
- Department of Surgery, University Hospital, Nottingham, UK
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