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Wong A, Sim N, Kam J, Rajarethinam R, Tan B, Tan A. The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap - A porcine model. JPRAS Open 2024; 40:150-157. [PMID: 38533305 PMCID: PMC10963183 DOI: 10.1016/j.jpra.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/11/2024] [Indexed: 03/28/2024] Open
Abstract
Background A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. Method A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. Results There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. Conclusion The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.
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Affiliation(s)
- A.W.J. Wong
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - N.H.S. Sim
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - J.H. Kam
- Hepato Pancreato Biliary Service, Department of General Surgery, Sengkang General Hospital, Singapore
| | - R. Rajarethinam
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), Singapore
| | - B.K. Tan
- Department of Plastic, Reconstructive & Aesthetic Surgery, Singapore General Hospital, Singapore
| | - A.Y.H. Tan
- Hepato Pancreato Biliary Service, Department of General Surgery, Sengkang General Hospital, Singapore
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Harris MC, Atanasov G, Neo EN, Goldfinch A, Ng AJH, Tew K, Kuan L, Trochsler M, Kanhere H. Value of the surgical pancreatic duct anatomy and associated outcomes in pancreatic cancer. ANZ J Surg 2024. [PMID: 38426386 DOI: 10.1111/ans.18903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures. METHODS Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS. RESULTS Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence-free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival. DISCUSSION These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high-risk patients and delivering a personalized surgical approach with prognosis stratification.
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Affiliation(s)
- Mark Conor Harris
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Georgi Atanasov
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Eu Nice Neo
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Goldfinch
- Department of Radiology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Andrew Jin-Hean Ng
- Department of Radiology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Khimseng Tew
- Department of Radiology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Lilian Kuan
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Trochsler
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Harsh Kanhere
- Upper Gastrointestinal and Hepatobiliary Unit, Department of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Garcés-Durán R, Monino L, Deprez PH, Piessevaux H, Moreels TG. Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP. Hepatobiliary Pancreat Dis Int 2023:S1499-3872(23)00115-7. [PMID: 37495491 DOI: 10.1016/j.hbpd.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. METHODS We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. RESULTS Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76 (90%) procedures and clinical success rate of 30/34 (88%) patients. Mild adverse event rate was 8/76 (11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30 (80%) procedures (P = 0.194 vs. biliary SBE-ERCP) and clinical success rate of 11/17 (65%) patients (P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30 (20%) (P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. CONCLUSIONS Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.
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Affiliation(s)
- Rodrigo Garcés-Durán
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Laurent Monino
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Pierre H Deprez
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Hubert Piessevaux
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrates 10, 1200 Brussels, Belgium
| | - Tom G Moreels
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Avenue Hippocrates 10, 1200 Brussels, Belgium.
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Luo Y, Tacey M, Hodgson R, Houli N, Yong T. Haemoglobin drift in patients following Whipple's procedure. ANZ J Surg 2023; 93:1833-1838. [PMID: 36906924 DOI: 10.1111/ans.18363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUNDS This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift. METHODS A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details. RESULTS A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis. CONCLUSION Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.
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Affiliation(s)
- Yuchen Luo
- Division of Surgery, Northern Health, Epping, Victoria, Australia
| | - Mark Tacey
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Russell Hodgson
- Division of Surgery, Northern Health, Epping, Victoria, Australia
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
| | - Nezor Houli
- Division of Surgery, Northern Health, Epping, Victoria, Australia
- Department of Surgery, Western Health, Footscray, Victoria, Australia
| | - Tuck Yong
- Division of Surgery, Northern Health, Epping, Victoria, Australia
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Desai GS, Singh S, Pande PM, Wagle PK. Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases. Surg J (N Y) 2021; 7:e301-e306. [PMID: 34926811 PMCID: PMC8674093 DOI: 10.1055/s-0041-1736670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 09/03/2021] [Indexed: 10/27/2022] Open
Abstract
Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.
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Affiliation(s)
- Gunjan S Desai
- Department of Surgical Oncology, S. L. Raheja (A Fortis Associate) Hospital, Mahim (West), Mumbai, Maharashtra, India
| | - Sandip Singh
- Department of General Surgery, Lilavati Hospital and Research Centre, Bandra (West), Mumbai, Maharashtra, India
| | - Prasad M Pande
- Department of Surgical Oncology, S. L. Raheja (A Fortis Associate) Hospital, Mahim (West), Mumbai, Maharashtra, India
| | - Prasad K Wagle
- Department of Surgical Gastroenterology, Lilavati Hospital and Research Centre, Bandra West, Mumbai, Maharashtra, India
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Luu AM, Braumann C, Belyaev O, Janot-Matuschek M, Rudolf H, Praktiknjo M, Uhl W. Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int 2021; 20:271-278. [PMID: 33349608 DOI: 10.1016/j.hbpd.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 12/02/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) has the worst prognosis of all malignant tumors due to unavailable screening methods, late diagnosis with a low proportion of resectable tumors and resistance to systemic treatment. Complete tumor resection remains the cornerstone of modern multimodal strategies aiming at long-term survival. This study was performed to investigate the overall rate of long-term survival (LTS) and its contributing factors. METHODS This was a retrospective single-center analysis of consecutive patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2007 and 2014 at the St. Josef Hospital, Ruhr University Bochum, Germany. Clinical and laboratory parameters were assessed and evaluated for prediction of LTS with Cox regression analysis. RESULTS The overall rate of LTS after PD for PDAC was 20.4% (34/167). Median survival was 24 months regardless of adjuvant treatment. Carbohydrate antigen 19-9 levels, tumor grade, lymph vessel invasion, perineural invasion and reduced general condition were significantly associated with LTS in univariate analysis (P < 0.05). Serum levels of carbohydrate antigen 19-9, American Joint Committee on Cancer stage, tumor grade, abdominal pain, male, exocrine pancreatic insufficiency and duration of postoperative hospital stay were independent predictors of cancer survival in multivariable analysis. CONCLUSIONS Cancer related characteristics are associated with LTS in multimodally treated patients after curative PDAC surgery.
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Affiliation(s)
- Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, Bochum 44791, Germany.
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, Bochum 44791, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, Bochum 44791, Germany
| | - Monika Janot-Matuschek
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, Bochum 44791, Germany
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Universitaetsstrasse 105, Bochum 44789, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine, University of Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum, Gudrunstrasse 56, Bochum 44791, Germany
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Wu L, Nahm CB, Jamieson NB, Samra J, Clifton-Bligh R, Mittal A, Tsang V. Risk factors for development of diabetes mellitus (Type 3c) after partial pancreatectomy: A systematic review. Clin Endocrinol (Oxf) 2020; 92:396-406. [PMID: 32017157 DOI: 10.1111/cen.14168] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 02/02/2020] [Accepted: 02/02/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Type 3c diabetes mellitus (T3cDM) occurring post pancreatectomy can be challenging to treat due to the frequent combination of decreased circulating levels of insulin and glucagon and concurrent exocrine insufficiency. Relatively, little is known regarding the risk factors for development of T3cDM post pancreatectomy. Our aim was to review the literature and assess what is known of the risk factors for the development of new-onset DM following partial pancreatic resection and where possible determines the incidence, time of onset and the management approach to hyperglycaemia in this context. DESIGN Medline and Embase databases were reviewed using specific keyword criteria. Original manuscripts published in 1990 or later included. Articles with study population <20, lacking information on new-onset DM, follow-up duration or specifically targeting rare procedures/pathology were excluded. The Newcastle Ottawa Quality Assessment form was applied. Results reported according to PRISMA guidelines. Pooled effect size calculated using random effects model. PATIENTS Thirty six articles were identified that described a total of 5636 patients undergoing pancreaticoduodenectomy, 3922 patients having distal pancreatectomy and 315 with central pancreatectomy. RESULTS The incidence of new-onset DM was significantly different between different types of resection from 9% to 24% after pancreaticoduodenectomy (pooled estimate 16%; 95% CI: 14%-17%), 3%-40% after distal pancreatectomy (pooled estimate 21%; 95% CI: 16%-25%) and 0%-14% after central pancreatectomy (pooled estimate 6%; 95% CI: 3%-9%). Surgical site, higher preoperative HbA1c, fasting plasma glucose and lower remnant pancreatic volume had strongest associations with new-onset DM. CONCLUSIONS This systematic review supports that risk of development of T3cDM is associated with type of pancreatic resection, lower remnant pancreatic volume and higher preoperative HbA1c.
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Affiliation(s)
- Linda Wu
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nigel B Jamieson
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jaswinder Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medical and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Venessa Tsang
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Sydney Medical School Northern, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Luu AM, Krasemann L, Fahlbusch T, Belyaev O, Janot-Matuschek M, Uhl W, Braumann C. Facing the surgeon's nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). J Hepatobiliary Pancreat Sci 2020; 27:171-181. [PMID: 31951086 DOI: 10.1002/jhbp.713] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality. METHODS We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). RESULTS A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors (P < .05). Reoperation was necessary in all affected patients on postoperative day 12 ± 9 on average. Mortality was significantly associated with POPF grade C (P < .05) being present in 39.1% (9/23). CONCLUSIONS POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice.
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Affiliation(s)
- Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Lukas Krasemann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Tim Fahlbusch
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Monika Janot-Matuschek
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
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Karavias D, Thomas P, Koh A, Irving G, Navarro AP, Cameron IC, Gomez D. Statin therapy does not influence the outcome of patients undergoing surgery for pancreatic cancer. ANZ J Surg 2019; 90:1671-1676. [PMID: 31845479 DOI: 10.1111/ans.15600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently, statins have been associated with improved survival in certain cancers. The aim of this study was to evaluate the impact of statins on the outcome of patients undergoing surgery for pancreatic cancer. In addition, the effect of statins on the histopathological characteristics of the disease was assessed. METHODS A retrospective review of the prospectively maintained hepato-pancreatico-biliary database was performed and patients with pancreatic cancer who underwent surgery between January 2014 and December 2017 were included. Statistical analysis was performed to assess the impact of statins on histopathological characteristics and survival outcome. RESULTS A total of 151 patients were included, of whom 71 underwent pancreatic resections and 80 underwent trial dissection and bypass procedures. In the operated group, 20 patients were on statin therapy preoperatively. With respect to disease-free survival, tumour size (P = 0.023) and lymphatic invasion (P = 0.015) were significant variables on univariate analysis. Gender (P = 0.022), adjuvant chemotherapy (P < 0.001), lymphatic invasion (P = 0.021) and tumour size (P = 0.041) were significant variables on univariate analysis with respect to overall survival. Multivariate analysis identified adjuvant chemotherapy as the only independent predictor of overall survival (P < 0.001). No correlations between the use of statins and the histopathological characteristics were identified. CONCLUSION Adjuvant chemotherapy is an independent predictor of overall survival in patients undergoing surgery for pancreatic cancer. Statin therapy does not influence survival outcomes and histopathological characteristics following surgery for pancreatic cancer.
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Affiliation(s)
- Dimitrios Karavias
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul Thomas
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Koh
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Glen Irving
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alex P Navarro
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iain C Cameron
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dhanny Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Nottingham Digestive Disease Biomedical Research Unit, The University of Nottingham, Nottingham, UK
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10
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Sahaab E, Iqbal N, Bhatti ABH. Successful outcome after Pancreaticodoudenectomy in an elderly cirrhotic patient: A case report. Int J Surg Case Rep 2019; 58:18-20. [PMID: 30999147 DOI: 10.1016/j.ijscr.2019.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/22/2019] [Indexed: 02/08/2023] Open
Abstract
Pancreaticodoudenectomy in cirrhotic patients is seldom attempted. It is associated with high morbidity and mortality rates. Careful patient selection allows its safe performance in cirrhotic patients. Preoperative biliary drainages should always be considered. Liver cirrhosis is not an absolute contraindication to PD.
Introduction Cirrhosis is a risk factor for poor outcomes in non-hepatic oncological resections. There are only a handful of cases demonstrating outcomes of pancreaticoduodenectomy (PD) in patients with pancreatic cancer and underlying cirrhosis. Moreover, pushing the limits of PD to elderly cirrhotic patients and demonstrating its safety remains under reported. Case presentation Here, we report successful management of a 71 year-old-lady with HCV related liver cirrhosis, obstructive jaundice and poor performance status, who was medically optimized and then underwent PD for adenocarcinoma of the head of pancreas. There was no major post-operative morbidity except minor chyle leak which resolved spontaneously. On her last follow up, she was doing well and undergoing adjuvant chemotherapy. Discussion Preoperative medical optimization and careful patient selection can yield successful outcomes even after a major abdominal surgery like PD in elderly patients with underlying liver cirrhosis. Conclusion Liver cirrhosis is not a contra indication to PD in elderly patients with good performance status.
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Abstract
BACKGROUND The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival. METHODS An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic. RESULTS Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection. CONCLUSION The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.
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Affiliation(s)
- Sanjay Pandanaboyana
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Richard Bell
- Department of Hepatobiliary and Pancreatic Surgery, St James Hospital, Leeds, UK
| | - John Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
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Pillai SA, Palaniappan R, Pichaimuthu A, Rajendran KK, Sathyanesan J, Govindhan M. Feasibility of implementing fast-track surgery in pancreaticoduodenectomy with pancreaticogastrostomy for reconstruction--a prospective cohort study with historical control. Int J Surg 2014; 12:1005-9. [PMID: 25014648 DOI: 10.1016/j.ijsu.2014.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 06/25/2014] [Accepted: 07/02/2014] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Fast track programmes have been introduced in pancreatic surgery, but the data are sparse. The aim of this prospective study was to analyse the feasibility of implementing fast track rehabilitation protocol in PD with pancreaticogastrostomy, using historical control for comparison. MATERIALS AND METHODS Between April 2012 and December 2012, twenty patients who underwent PD (with pancreaticogastrostomy) were managed by a fast-track rehabilitation protocol. These patients were compared with an equal number of historical controls treated according to the traditional protocol. RESULTS Patients in the fast track group were able to tolerate liquid (p = 0.0005) and solid diet (p = 0.0001) earlier, and they passed stools earlier (p = 0.02). Delayed gastric emptying (DGE) was significantly reduced in the fast track group (p = 0.02). There was no difference in the rates of pancreatic fistula (PF), post pancreatectomy haemorrhage (PPH) and mortality between the two groups. Length of hospital stay was reduced in the fast track group (median 14 vs 18.5, p = 0.007). CONCLUSION Fast track programme appears to be feasible in PD, even with pancreatico-gastric anastomosis. It is associated with early recovery, reduced DGE and reduced hospital stay.
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Affiliation(s)
- Sastha Ahanatha Pillai
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
| | - Ravichandran Palaniappan
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
| | - Anbalagan Pichaimuthu
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
| | - Kamala Kannan Rajendran
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
| | - Jeswanth Sathyanesan
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
| | - Manoharan Govindhan
- Institute of Surgical Gastroenterology and Liver Transplantation, Government Stanley Medical College, Chennai 600001, India.
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Manuballa V, Amin M, Cappell MS. Clinical presentation and comparison of surgical outcome for segmental resection vs. Whipple's procedure for solid pseudopapillary tumor: Report of six new cases & literature review of 321 cases. Pancreatology 2013; 14:71-80. [PMID: 24555981 DOI: 10.1016/j.pan.2013.11.007] [Citation(s) in RCA: 7] [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] [Received: 05/10/2013] [Revised: 09/12/2013] [Accepted: 11/14/2013] [Indexed: 12/11/2022]
Abstract
AIM Report 6 new cases of solid-pseudopapillary-pancreatic-tumor, comprehensively review 321 cases reported in American literature, and compare outcomes for segmental resection vs.. Whipple's procedure. METHODS Cases of solid-pseudopapillary-tumor at William Beaumont Hospital, 1999-2011, identified by computerized analysis of pathology reports. Comprehensive review of all American cases identified by computerized literature review. Segmental resection includes open/laparoscopic central pancreatectomy and anatomic distal pancreatectomy, but excludes enucleation. RESULTS Six cases of solid-pseudopapillary-pancreatic-tumors (0.5% of all solid pancreatic lesions), occurred during 1999-2011 at the hospital. Mean age at diagnosis = 27.7 years. All 6 were female. All patients had abdominal pain. Mean symptom duration = 10.0 days. All patients had normal routine blood tests. Mean APACHE II score at diagnosis = 1.8. All six patients had single heterogeneous lesions, with cystic/solid components. All patients underwent surgery: segmental resection-4, Whipple's procedure-2. Tumors were uniformly diagnosed by surgically resected tissue. Mean tumor size = 5.7 cm. Mean postoperative length of stay = 4.0 days for segmental resection (N = 4) vs. 14.0 days for Whipple's procedure (N = 2). All 6 patients are alive and well to-date, without evident local recurrence or metastasis. In a literature review, 45 patients undergoing Whipple's procedure versus 34 patients undergoing segmental resection, had significantly longer mean postoperative hospitalization (16.4 vs. 4.3 days, p = 0.01), and had increased unadjusted mortality (20.2% vs. 2.2%, p = 0.018). However, this mortality difference became insignificant when adjusting for longer mean follow-up of Whipple's procedure patients (Kaplan-Meier-survival-curve, p = 0.75). CONCLUSIONS This work suggests segmental resection of these pancreatic tumors localized to the body/tail may have a better surgical outcome than Whipple's procedure for tumors localized to the pancreatic head. Further studies are necessary.
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Affiliation(s)
| | - Mitual Amin
- William Beaumont Hospital, Royal Oak, MI, USA; Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Mitchell S Cappell
- William Beaumont Hospital, Royal Oak, MI, USA; Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA.
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Krishna A, Bansal VK, Kumar S, Sridhar P, Kapoor S, Misra MC, Garg P. Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy. Indian J Surg 2013; 77:703-7. [PMID: 26730093 DOI: 10.1007/s12262-013-0992-3] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022] Open
Abstract
Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.
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Affiliation(s)
- Asuri Krishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - P Sridhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Sameer Kapoor
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Mahesh C Misra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Pramod Garg
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
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Badger SA, Brant JL, Jones C, McClements J, Loughrey MB, Taylor MA, Diamond T, McKie LD. The role of surgery for pancreatic cancer: a 12-year review of patient outcome. Ulster Med J 2010; 79:70-5. [PMID: 21116422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/18/2010] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Pancreatic cancer has a poor prognosis with <5% alive at 5 years, despite active surgical treatment. The study aim was to review patients undergoing pancreatic resection and assess the effect of clinical and pathological parameters on survival. PATIENTS AND METHODS All patients who had undergone radical pancreatic surgery, January 1996 to December 2008, were identified from the unit database. Additional information was retrieved from the patient records. The demographic, clinical, and pathological records were recorded using Microsoft Excel. Survival was assessed using Kaplan-Meier and predictors of survival determined by multinominal logistic regression and log rank test. RESULTS 126 patients were identified from the database. The majority (106) had a Whipple's procedure, 14 had a distal pancreatectomy and 6 had local periampullary excision. The average age of the Whipple's group of patients was 61.7 years (± 11.7) with most procedures performed for malignancy (n=100). Survival was worse with adenocarcinoma compared to all other pathologies (p=0.013), while periampullary tumours had a better prognosis compared to other locations (p=0.019). Survival decreased with poorer differentiation (p=0.001), increasing pT (p<0.001) and pN stage (p<0.001). Survival was worse with perineural (p=0.04) or lymphovascular invasion (p=0.05). A microscopic postive resection margin (R1) was associated with a worse survival (p=0.007). Tumour differentiation (p=0.001) and positive nodal status (p<0.001) were found to be independent predictors of mortality. CONCLUSION Tumour differentiation and nodal status are important predictors of outcome. A positive resection margin is associated with a poorer survival.
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