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Chen JW, Lof S, Zwart MJW, Busch OR, Daams F, Festen S, Fong ZV, Hogg ME, Slooter MD, Nieveen van Dijkum EJ, Besselink MG. Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study. Ann Surg Open 2023; 4:e354. [PMID: 38144496 PMCID: PMC10735109 DOI: 10.1097/as9.0000000000000354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023] Open
Abstract
Background A potential downside of robotic pancreatoduodenectomy (RPD) is the lack of tactile feedback when tying sutures, which could be especially perilous during pancreatic anastomosis. Near-infrared fluorescence imaging with indocyanine green (NIRF-ICG) could detect transpancreatic-suture-induced hypoperfusion of the pancreatic stump during RPD, which may be related to postoperative pancreatic fistula (POPF) grade B/C, but studies are lacking. Methods This prospective study included 37 patients undergoing RPD to assess the relation between pancreatic stump hypoperfusion as objectified with NIRF-ICG using Firefly and the rate of POPF grade B/C. In 27 patients, NIRF-ICG was performed after tying down the transpancreatic U-sutures. In 10 'negative control' patients, NIRF-ICG was performed before tying these sutures. Results Pancreatic stump hypoperfusion was detected using NIRF-ICG in 9/27 patients (33%) during RPD. Hypoperfusion was associated with POPF grade B/C (67% [6/9 patients] versus 17% [3/18 patients], P = 0.026). No hypoperfusion was objectified in 10 'negative controls'. Conclusions Transpancreatic-suture-induced pancreatic stump hypoperfusion can be detected using NIRF-ICG during RPD and was associated with POPF grade B/C. Surgeons could use NIRF-ICG to adapt their suturing approach during robotic pancreatico-jejunostomy. Further larger prospective studies are needed to validate the association between transpancreatic-suture-induced hypoperfusion and POPF.
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Affiliation(s)
- Jeffrey W. Chen
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Sanne Lof
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Maurice J. W. Zwart
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Olivier R. Busch
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, OLVG, Location Oost, Amsterdam, The Netherlands
| | - Zhi Ven Fong
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ
| | - Melissa E. Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, IL
| | - Maxime D. Slooter
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Els J.M. Nieveen van Dijkum
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
| | - Marc G. Besselink
- From the Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and Quality of life, Amsterdam, The Netherlands
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Ozsay O, Aydin MC, Karabulut K, Basoglu M, Dilek ON. Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience. Acta Chir Belg 2023:1-8. [PMID: 37767719 DOI: 10.1080/00015458.2023.2264630] [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: 01/12/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. METHODS A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients' data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. RESULTS Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm 'Y'-shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm 'Y'-shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5-21.0 months). The median follow-up time was 12.2 months (3.0-45 months). CONCLUSIONS During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with 'Y'-shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.
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Affiliation(s)
- Oguzhan Ozsay
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Mehmet Can Aydin
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Kagan Karabulut
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Mahmut Basoglu
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Osman Nuri Dilek
- Department of General Surgery, Katip Çelebi University School of Medicine, İzmir, Turkey
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Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [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] [Indexed: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
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Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
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Scholer AJ, Marcus R, Garland-Kledzik M, Chang SC, Khader A, Santamaria-Barria J, Jutric Z, Wolf R, Goldfarb M. Validating biologic age in selecting elderly patients with pancreatic cancer for surgical resection. J Surg Oncol 2023; 127:394-404. [PMID: 36321409 PMCID: PMC10092356 DOI: 10.1002/jso.27121] [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: 07/19/2022] [Revised: 09/03/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Selecting frail elderly patients with pancreatic cancer (PC) for pancreas resection using biologic age has not been elucidated. This study determined the feasibility of the deficit accumulation frailty index (DAFI) in identifying such patients and its association with surgical outcomes. METHODS The DAFI, which assesses frailty based on biologic age, was used to identify frail patients using clinical and health-related quality-of-life data. The characteristics of frail and nonfrail patients were compared. RESULTS Of 242 patients (median age, 75.5 years), 61.2% were frail and 32.6% had undergone pancreas resection (surgery group). Median overall survival (mOS) decreased in frail patients (7.13 months, 95% confidence interval [CI]: 5.65-10.1) compared with nonfrail patients (16.1 months, 95% CI: 11.47-34.40, p = 0.001). In the surgery group, mOS improved in the nonfrail patients (49.4%; 49.2 months, 95% CI: 29.3-79.9) compared with frail patients (50.6%, 22.1 months, 95% CI: 18.3-52.4, p = 0.10). In the no-surgery group, mOS was better in nonfrail patients (54%; 10.81 months, CI 7.85-16.03) compared with frail patients (66%; 5.45 months, 95% CI: 4.34-7.03, p = 0.02). CONCLUSIONS The DAFI identified elderly patients with PC at risk of poor outcomes and can identify patients who can tolerate more aggressive treatments.
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Affiliation(s)
- Anthony J Scholer
- Division of Surgical Oncology, University of South Carolina School of Medicine, Greenville, South Carolina, USA
| | - Rebecca Marcus
- Department of Surgery, Saint John's Cancer Institute at Providence St. John's Health Center, Santa Monica, California, USA
| | - Mary Garland-Kledzik
- Division of Surgical Oncology, West Virginia University, Morgantown, West Virginia, USA
| | - Shu-Chin Chang
- Department of Surgery, Medical Data Research Center, Providence Saint Joseph Health, Oregon, Portland, USA
| | - Adam Khader
- Department of Surgery, Division of Surgical Oncology, Hunter Holmes McGuire Veterans Affair Medical Center, Richmond, Virginia, USA
| | - Juan Santamaria-Barria
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Zeljka Jutric
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California Irvine Medical Center, Orange, California, USA
| | - Ronald Wolf
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, University of California Irvine Medical Center, Orange, California, USA
| | - Melanie Goldfarb
- Department of Surgery, Saint John's Cancer Institute at Providence St. John's Health Center, Santa Monica, California, USA
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Yan Y, Hua Y, Chang C, Zhu X, Sha Y, Wang B. Laparoscopic versus open pancreaticoduodenectomy for pancreatic and periampullary tumor: A meta-analysis of randomized controlled trials and non-randomized comparative studies. Front Oncol 2023; 12:1093395. [PMID: 36761416 PMCID: PMC9905842 DOI: 10.3389/fonc.2022.1093395] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023] Open
Abstract
Objective This meta-analysis compares the perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to those of open pancreaticoduodenectomy (OPD) for pancreatic and periampullary tumors. Background LPD has been increasingly applied in the treatment of pancreatic and periampullary tumors. However, the perioperative outcomes of LPD versus OPD are still controversial. Methods PubMed, Web of Science, EMBASE, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) comparing LPD versus OPD for pancreatic and periampullary tumors. The main outcomes were mortality, morbidity, serious complications, and hospital stay. The secondary outcomes were operative time, blood loss, transfusion, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), bile leak (BL), delayed gastric emptying (DGE), lymph nodes harvested, R0 resection, reoperation, and readmission. RCTs were evaluated by the Cochrane risk-of-bias tool. NRCTs were assessed using a modified tool from the Methodological Index for Non-randomized Studies. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42022338832). Results Four RCTs and 35 NRCTs concerning a total of 40,230 patients (4,262 LPD and 35,968 OPD) were included. Meta-analyses showed no significant differences in mortality (OR 0.91, p = 0.35), serious complications (OR 0.97, p = 0.74), POPF (OR 0.93, p = 0.29), PPH (OR 1.10, p = 0.42), BL (OR 1.28, p = 0.22), harvested lymph nodes (MD 0.66, p = 0.09), reoperation (OR 1.10, p = 0.41), and readmission (OR 0.95, p = 0.46) between LPD and OPD. Operative time was significantly longer for LPD (MD 85.59 min, p < 0.00001), whereas overall morbidity (OR 0.80, p < 0.00001), hospital stay (MD -2.32 days, p < 0.00001), blood loss (MD -173.84 ml, p < 0.00001), transfusion (OR 0.62, p = 0.0002), and DGE (OR 0.78, p = 0.002) were reduced for LPD. The R0 rate was higher for LPD (OR 1.25, p = 0.001). Conclusions LPD is associated with non-inferior short-term surgical outcomes and oncologic adequacy compared to OPD when performed by experienced surgeons at large centers. LPD may result in reduced overall morbidity, blood loss, transfusion, and DGE, but longer operative time. Further RCTs should address the potential advantages of LPD over OPD. Systematic review registration PROSPERO, identifier CRD42022338832.
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Affiliation(s)
- Yong Yan
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yinggang Hua
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Cheng Chang
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Xuanjin Zhu
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yanhua Sha
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China,*Correspondence: Yanhua Sha, ; Bailin Wang,
| | - Bailin Wang
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,*Correspondence: Yanhua Sha, ; Bailin Wang,
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Enderes J, Pillny C, Standop J, Manekeller S, Kalff JC, Glowka TR. Operative Re-Intervention following Pancreatoduodenectomy: What Has Changed over the Last Decades. J Clin Med 2022; 11. [PMID: 36556127 DOI: 10.3390/jcm11247512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Background: To investigate changes over the last decades in the management of postoperative complications following pancreatoduodenectomy (PD) with special emphasis on reoperations, their indications, and outcomes. Methods: 409 patients who underwent PD between 2008 and 2021 were retrospectively analyzed with respect to their need for reoperations (reoperation, n = 81, 19.8% vs. no reoperation, n = 328, 80.2%). The cohort was then compared to a second cohort comprising patients who underwent PD between 1989 and 2007 (n = 285). Results: 81 patients (19.8%) underwent reoperation. The main cause of reoperation was the dehiscence of pancreatogastrostomy (22.2%). Reoperation was associated with a longer duration of the index operation, more blood loss, and more erythrocyte concentrates being transfused. Patients who underwent reoperation showed more postoperative complications and a higher mortality rate (25% vs. 2%, p < 0.001). Compared to the earlier cohort, the observed increase in reoperations did not lead to increased mortality (5% vs. 6%, p = 353). Conclusions: The main cause for reoperation has changed over the last decades and was the dehiscence of pancreatogastrostomy. Associated with a leakage of pancreatic fluid and clinically relevant PF, it remains the most devastating complication following PD. Strategies for prevention and treatment, e.g., by endoscopic vacuum-assisted-closure therapy are of utmost importance.
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Smyrniotis V, Parasyris S, Gemenetzis G, Margaris I, Petropoulou Z, Papadoliopoulou M, Sidiropoulos T, Dellaportas D, Vezakis A, Polydorou A, Kokoropoulos P, Theodoraki K, Matsota P, Vassiliu P, Arkadopoulos N. Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration. Ann Surg Open 2022; 3:e161. [PMID: 37601609 PMCID: PMC10431257 DOI: 10.1097/as9.0000000000000161] [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: 09/06/2021] [Accepted: 04/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome. Methods The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed. Results Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C). Conclusion Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.
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Affiliation(s)
- Vasileios Smyrniotis
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros Parasyris
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Gemenetzis
- Hepatobiliary and Pancreatic Unit, Royal Infirmary Edinburgh, Edinburgh, United Kingdom
| | - Ioannis Margaris
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Zoe Petropoulou
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Papadoliopoulou
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Sidiropoulos
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dionysios Dellaportas
- Department of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Vezakis
- Department of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Polydorou
- Department of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Kokoropoulos
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Matsota
- Department of Anesthesiology, Attikon University General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panteleimon Vassiliu
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Arkadopoulos
- From the Department of Surgery, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Enderes J, Pillny C, Matthaei H, Manekeller S, Kalff JC, Glowka TR. Obesity Does Not Influence Delayed Gastric Emptying Following Pancreatoduodenectomy. Biology (Basel) 2022; 11:biology11050763. [PMID: 35625491 PMCID: PMC9138317 DOI: 10.3390/biology11050763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022]
Abstract
Background: The data about obesity on postoperative outcome after pancreatoduodenectomy (PD) are inconsistent, specifically in relation to gastric motility and delayed gastric emptying (DGE). Methods: Two hundred and eleven patients were included in the study and patients were retrospectively analyzed in respect to pre-existing obesity (obese patients having a body mass index (BMI) ≥ 30 kg/m2 vs. non-obese patients having a BMI < 30 kg/m2, n = 34, 16% vs. n = 177, 84%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications with special emphasis on DGE. Results: Obese patients were more likely to develop clinically relevant pancreatic fistula grade B/C (p = 0.008) and intraabdominal abscess formations (p = 0.017). However, clinically relevant DGE grade B/C did not differ (p = 0.231) and, specifically, first day of solid food intake (p = 0.195), duration of intraoperative administered nasogastric tube (NGT) (p = 0.708), rate of re-insertion of NGT (0.123), total length of NGT (p = 0.471) or the need for parenteral nutrition (p = 0.815) were equally distributed. Moreover, mortality (p = 1.000) did not differ between the two groups. Conclusions: Obese patients do not show a higher mortality rate and are not at higher risk to develop DGE. We thus show that in our study, PD is feasible in the obese patient in regard to postoperative outcome with special emphasis on DGE.
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Özşay O, Aydın MC. Effect of Modified Blumgart Anastomosis on Surgical Outcomes After Pancreaticoduodenectomy. Turk J Gastroenterol 2022; 33:119-126. [PMID: 35238780 PMCID: PMC9128342 DOI: 10.5152/tjg.2021.21701] [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] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/04/2021] [Indexed: 09/17/2023]
Abstract
BACKGROUND Surgeons continue to be concerned about complications after pancreaticoduodenectomy, especially postoperative pancreatic fistula. Among the factors that cause postoperative pancreatic fistula, the pancreaticojejunostomy technique has stood out in recent studies. In this study, we aimed to compare the surgical outcomes, especially POPF, of the modified Blumgart and the traditional anastomosis techniques in patients who underwent pancreaticoduodenectomy. METHODS A total of 144 patients who underwent pancreaticoduodenectomy were divided into 2 groups according to the performed pancreaticojejunostomy technique (modified Blumgart anastomosis, n = 91 and traditional anastomosis, n = 53). Preoperative clinicodemographic data, perioperative findings, and postoperative results were compared between the groups. Additionally, factors associated with clinically relevant postoperative pancreatic fistula were analyzed. RESULTS The modified Blumgart anastomosis group had lower clinically relevant postoperative pancreatic fistula rate than traditional anastomosis group (n = 8 (8.8%) versus n = 14 (26.4%), P = .005). On the contrary, the biochemical leakage rate was higher in the modified Blumgart anastomosis group (n = 30 (33%) versus n = 9 (17%), P = .037). While postoperative pancreatic fistula-related reoperation rate was lower (n = 2 (2.2%) versus n = 7 (13.2%), P = .013), the length of hospital stay was also shorter (11 days (5-47 days) versus 21 days (6-46 days), P < .001) in the modified Blumgart anastomosis group. Univariate and multivariate analyses revealed that modified Blumgart anastomosis was an independent and negative predictive factor for clinically relevant postoperative pancreatic fistula (odds ratio = 0.274, 95% confidence interval = 0.103-0.728, P = .009). CONCLUSION Compared to the traditional anastomosis, modified Blumgart anastomosis decreases the rate of transition from biochemical leakage to clinically relevant postoperative pancreatic fistula and postoperative pancreatic fistula-related reoperation and also shortens the length of hospital stay. In addition, modified Blumgart anastomosis is an independent and negative predictive factor for the development of clinically relevant postoperative pancreatic fistula.
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Affiliation(s)
- Oğuzhan Özşay
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Mehmet Can Aydın
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
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Takchi R, Cos H, Williams GA, Woolsey C, Hammill CW, Fields RC, Strasberg SM, Hawkins WG, Sanford DE. Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay. HPB (Oxford) 2022; 24:65-71. [PMID: 34183246 PMCID: PMC9446414 DOI: 10.1016/j.hpb.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. METHODS Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. RESULTS 494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615). CONCLUSION ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.
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Affiliation(s)
- Rony Takchi
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Heidy Cos
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Cheryl Woolsey
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.
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11
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Feng Q, Liao W, Xin Z, Jin H, Du J, Cai Y, Liao M, Yuan K, Zeng Y. Laparoscopic Pancreaticoduodenectomy Versus Conventional Open Approach for Patients With Pancreatic Duct Adenocarcinoma: An Up-to-Date Systematic Review and Meta-Analysis. Front Oncol 2021; 11:749140. [PMID: 34778064 PMCID: PMC8578898 DOI: 10.3389/fonc.2021.749140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/30/2021] [Accepted: 09/28/2021] [Indexed: 02/05/2023] Open
Abstract
Background To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic versus open pancreaticoduodenectomy (LPD vs. OPD), we performed a meta-analysis of currently available propensity score matching studies and large-scale retrospective cohorts to compare the safety and overall effect of LPD to OPD for patients with PDAC. Methods A meta-analysis was registered at PROSPERO and the registration number is CRD42021250395. PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Data on operative times, blood loss, 30-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥3 complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, overall survival, and long-term survival) were subjected to meta-analysis. Results Overall, we identified 10 retrospective studies enrolling a total of 11,535 patients (1,514 and 10,021 patients underwent LPD and OPD, respectively). The present meta-analysis showed that there were no significant differences in overall survival time, 1-year survival, 2-year survival, 30-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, and lymph node dissection between the LPD and OPD groups. Nevertheless, compared with the OPD group, LPD resulted in significantly higher rate of R0 resection (OR: 1.22; 95% CI 1.06-1.40; p = 0.005), longer operative time (WMD: 60.01 min; 95% CI 23.23-96.79; p = 0.001), lower Clavien-Dindo grade ≥III rate (p = 0.02), less blood loss (WMD: -96.49 ml; 95% CI -165.14 to -27.83; p = 0.006), lower overall morbidity rate (OR: 0.65; 95% CI 0.50 to 0.85; p = 0.002), shorter LOS (MD = -2.73; 95% CI -4.44 to -1.03; p = 0.002), higher 4-year survival time (p = 0.04), 5-year survival time (p = 0.001), and earlier time to starting adjuvant chemotherapy after surgery (OR: -10.86; 95% CI -19.42 to -2.30; p = 0.01). Conclusions LPD is a safe and feasible alternative to OPD for patients with PDAC, and compared with OPD, LPD seemed to provide a similar OS. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/#recordDetails.
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Affiliation(s)
- Qingbo Feng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wenwei Liao
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zechang Xin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, Beijing, China
| | - Hongyu Jin
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jinpeng Du
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yunshi Cai
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Mingheng Liao
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Kefei Yuan
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Zeng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
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12
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Koek S, Wiegele S, Ballal M. Drain fluid amylase and lipase as a predictive factor of postoperative pancreatic fistula. ANZ J Surg 2021; 92:414-418. [PMID: 34676961 DOI: 10.1111/ans.17296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early detection of a postoperative pancreatic fistula (POPF) may improve outcomes after pancreaticoduodenectomy (PD). The aim was to assess the role of postoperative drain fluid amylase (DFA) and lipase (DFL) measurements as a predictive indicator in the development of POPF. METHODS This retrospective cohort study included all PD procedures performed between 2009 and 2017 at Fremantle and Fiona Stanley Hospital in Western Australia. The DFA and DFL measurements on postoperative day (POD) three and five were correlated with the development of POPF. RESULTS A total of 169 patients were included in this study with a mean age of 64 ± 11.3 years. Of these, 17 (10.1%) developed a clinically significant POPF. In patients who had both a DFA and DFL measured on both POD 3 and 5, DFA and DFL was significantly higher in patients who developed POPF than those who did not (P < 0.001). In a receiver operating characteristic curve analysis, the most accurate test was POD 3 DFL measurement with an AUC 0.85 (CI 0.75-0.95, P < 0.001). A negative predictive value of 97.4% was observed. DFA and DFL were concordant in 89.2% of cases on POD 3 and 90.6% of cases on POD 5. CONCLUSION In this study, DFL measured on POD 3 as a single measurement appears to carry the most benefit in prediction of clinically significant POPF. Reduction to a measurement on this day may lead to a reduction in cost, earlier drain removal and earlier identification of high-risk patients.
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Affiliation(s)
- Sharnice Koek
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Sophie Wiegele
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Mohammed Ballal
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
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13
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Feng Q, Xin Z, Qiu J, Xu M. Laparoscopic vs. Open Pancreaticoduodenectomy After Learning Curve: A Systematic Review and Meta-Analysis of Single-Center Studies. Front Surg 2021; 8:715083. [PMID: 34568416 PMCID: PMC8461253 DOI: 10.3389/fsurg.2021.715083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/26/2021] [Accepted: 08/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Although laparoscopic pancreaticoduodenectomy (LPD) is a safe and feasible treatment compared with open pancreaticoduodenectomy (OPD), surgeons need a relatively long training time to become technically proficient in this complex procedure. In addition, the incidence of complications and mortality of LPD will be significantly higher than that of OPD in the initial stage. This meta-analysis aimed to compare the safety and overall effect of LPD to OPD after learning curve based on eligible large-scale retrospective cohorts and randomized controlled trials (RCTs), especially the difference in the perioperative and short-term oncological outcomes. Methods: PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Only clinical studies reporting more than 40 cases for LPD were included. Data on operative times, blood loss, and 90-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien–Dindo ≥III complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, positive lymph node numbers, and tumor size) were subjected to meta-analysis. Results: Overall, the final analysis included 13 retrospective cohorts and one RCT comprising 2,702 patients (LPD: 1,040, OPD: 1,662). It seems that LPD has longer operative time (weighted mean difference (WMD): 74.07; 95% CI: 39.87–108.26; p < 0.0001). However, compared with OPD, LPD was associated with a higher R0 resection rate (odds ratio (OR): 1.43; 95% CI: 1.10–1.85; p = 0.008), lower rate of wound infection (OR: 0.35; 95% CI: 0.22–0.56; p < 0.0001), less blood loss (WMD: −197.54 ml; 95% CI −251.39 to −143.70; p < 0.00001), lower blood transfusion rate (OR: 0.58; 95% CI 0.43–0.78; p = 0.0004), and shorter LOS (WMD: −2.30 day; 95% CI −3.27 to −1.32; p < 0.00001). No significant differences were found in 90-day mortality, overall morbidity, Clavien–Dindo ≥ III complications, reoperation, POPF, DGE, PPH, lymph node dissection, positive lymph node numbers, and tumor size between LPD and OPD. Conclusion: Comparative studies indicate that after the learning curve, LPD is a safe and feasible alternative to OPD. In addition, LPD provides less blood loss, blood transfusion, wound infection, and shorter hospital stays when compared with OPD.
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Affiliation(s)
- Qingbo Feng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zechang Xin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepatobiliary and Pancreatic Surgery Unit I, Peking University Cancer Hospital & Institute, Beijing, China
| | - Jie Qiu
- Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Mei Xu
- Department of Ultrasound Diagnosis, Air Force Medical Centre, Beijing, China
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14
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Massaras D, Masourou Z, Papazian M, Psarras G, Polydorou A. Solid Pseudopapillary Tumor of the Pancreas in a 25-Year-Old Female: A Rare Entity of Pancreatic Tumors. Cureus 2021; 13:e14747. [PMID: 34084675 PMCID: PMC8164176 DOI: 10.7759/cureus.14747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 12/28/2022] Open
Abstract
Solid pseudopapillary neoplasms (SPMs) of the pancreas are extremely rare tumors of the pancreas that typically affect young women and have a favorable prognosis. Herein, we report a 25-year-old female with solid pseudopapillary tumor of the pancreas who presented with atypical epigastric pain. The patient underwent pancreatoduodenectomy (Whipple procedure). She remained asymptomatic and showed no signs of disease after one year of follow-up. This type of pancreatic tumors is amenable to cure after complete surgical resection, even in cases with capsular invasion, unlike any other malignant tumors of the pancreas.
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Affiliation(s)
- Dimitrios Massaras
- Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Zoi Masourou
- Anesthesiology, Aretaieio University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Maria Papazian
- Pathology, Aretaieio University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Grigorios Psarras
- 1st Department of Radiology, Aretaieio University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Andreas Polydorou
- Surgery, Aretaieio University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
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15
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Brown ZJ, Cloyd JM. Trends in the utilization of neoadjuvant therapy for pancreatic ductal adenocarcinoma. J Surg Oncol 2021; 123:1432-1440. [PMID: 33831253 DOI: 10.1002/jso.26384] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/18/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
For patients with localized pancreatic cancer, neoadjuvant therapy (NT) is increasingly delivered before surgery to maximize the receipt of multimodality therapy and the odds of a margin-negative resection. Three decades of refining the use of NT have led to its acceptance as a valid treatment approach for pancreatic adenocarcinoma. In this review, we discuss the rationale for and recent global trends in the utilization of NT for patients with pancreatic cancer.
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Affiliation(s)
- Zachary J Brown
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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16
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Kerawala AA, Jamal A, Saleem L. Signet ring cell cancer of Ampulla of Vater-first ever case reported in a teenager and a review of literature. Rare Tumors 2021; 13:20363613211007767. [PMID: 33912327 PMCID: PMC8047084 DOI: 10.1177/20363613211007767] [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: 10/29/2020] [Accepted: 03/15/2021] [Indexed: 11/15/2022] Open
Abstract
Ampullary cancers are rare accounting for 0.2% of all gastrointestinal cancers. Signet ring is a rare variant of adenocarcinoma, characterized by having more than 50% of mucin secreting cells and clinically having a worse prognosis. We present the case of a teenage girl with this tumor, the youngest ever reported in medical literature. An 18 years old girl with no significant past medical history presented to our clinic with symptoms of upper abdominal pain and jaundice. Her upper GI endoscopy showed an ampullary lesion which was biopsied—diagnosing it as adenocarcinoma. She underwent a pancreato-duodenectomy (Whipple’s procedure) with Child’s reconstruction and a feeding jejunostomy. Her final histopathology report was documented as infiltrating adenocarcinoma of Signet Ring variety arising from the Ampulla of Vater. Being such a rare entity, there is a lack of randomized trials advising the optimum treatment for such cases. Till then anecdotal experiences will drive the optimum management of this rare disease.
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Affiliation(s)
| | - Abid Jamal
- Cancer Foundation Hospital, Karachi, Pakistan
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17
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Huang Y, Damodaran Prabha R, Chua TC, Arena J, Kotecha K, Mittal A, Gill AJ, Samra JS. Safety and Efficacy of Pancreaticoduodenectomy in Octogenarians. Front Surg 2021; 8:617286. [PMID: 33604352 PMCID: PMC7884922 DOI: 10.3389/fsurg.2021.617286] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 10/14/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Abstract
Backgrounds: Pancreaticoduodenectomy (PD) remains the only hope of a cure in selected patients with pancreatic adenocarcinoma (PAC). With an aging population, there will be an increasing number of very elderly patients being diagnosed with PAC of whom a selected proportion would be suitable for PD. However, the literature on outcomes of elderly patients after PD remains ambiguous. Therefore, the aim of this study was to examine the safety and efficacy of PD in octogenarians with PAC. Methods: A retrospective analysis of 304 patients with PAC undergoing PD. Patients were divided into two age groups using age of 80 years old as the cut-off. Results: Overall mortality and major morbidity rates were 0.5 and 18.5%, respectively. The octogenarian group had a higher rate of mortality (6.3%, n = 1, p < 0.001), a higher rate of major morbidity (37.5%, n = 6, p = 0.042) and a longer hospital stay (p = 0.035). However, median survival of octogenarians was 15.6 months. Multivariate analysis showed age was not identified as a prognostic factor for major morbidity and overall survival. Conclusion: Age alone should not be an exclusion criterion for consideration of PD. With careful selection, PD can be safely performed in octogenarians. Elderly patients should be referred to a specialized unit for an objective assessment to determine the suitability for this aggressive but potential curative approach.
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Affiliation(s)
- Yeqian Huang
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,South Western Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Ramesh Damodaran Prabha
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Terence C Chua
- Department of Surgery, QE II Jubilee Hospital, Metro South Health, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia.,Discipline of Surgery, The University of Queensland, Brisbane, QLD, Australia
| | - Jennifer Arena
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Krishna Kotecha
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anubhav Mittal
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Anthony J Gill
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, St Leonards, NSW, Australia.,Deparment of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Jaswinder S Samra
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia.,Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
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18
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Nassour I, Winters SB, Hoehn R, Tohme S, Adam MA, Bartlett DL, Lee KK, Paniccia A, Zureikat AH. Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma. J Surg Oncol 2020; 122:234-242. [PMID: 32350882 DOI: 10.1002/jso.25958] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 02/05/2020] [Revised: 03/25/2020] [Accepted: 04/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC. STUDY DESIGN Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database. RESULTS We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.
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Affiliation(s)
- Ibrahim Nassour
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sharon B Winters
- UPMC Network Cancer Registry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard Hoehn
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mohamed A Adam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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19
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Abstract
Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple's operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple's operation to be performed in the Caribbean.
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Affiliation(s)
- Yardesh Singh
- Surgery, University of the West Indies, St. Augustine, TTO
| | | | | | | | - Vijay Naraynsingh
- Surgery, Medical Associates Hospital, St. Joseph, TTO.,Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO
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20
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Zaghal A, Tamim H, Habib S, Jaafar R, Mukherji D, Khalife M, Mailhac A, Faraj W. Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma. Scand J Surg 2019; 109:228-237. [PMID: 30931801 DOI: 10.1177/1457496919840960] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality. METHODS Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index. RESULTS A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category. CONCLUSION To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.
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Affiliation(s)
- A Zaghal
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - H Tamim
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Habib
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - R Jaafar
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - D Mukherji
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Khalife
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Mailhac
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - W Faraj
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Singh AN, Pal S, Mangla V, Kilambi R, George J, Dash NR, Chattopadhyay TK, Sahni P. Pancreaticojejunostomy: Does the technique matter? A randomized trial. J Surg Oncol 2017; 117:389-396. [PMID: 29044532 DOI: 10.1002/jso.24873] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 07/17/2017] [Accepted: 09/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. METHODS This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. RESULTS A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. DISCUSSION The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).
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Affiliation(s)
- Anand N Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Mangla
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Joseph George
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar R Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar K Chattopadhyay
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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22
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Cloyd JM, Crane CH, Koay EJ, Das P, Krishnan S, Prakash L, Snyder RA, Varadhachary GR, Wolff RA, Javle M, Shroff RT, Fogelman D, Overman M, Wang H, Maitra A, Lee JE, Fleming JB, Katz MHG. Impact of hypofractionated and standard fractionated chemoradiation before pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Cancer 2016; 122:2671-9. [PMID: 27243381 PMCID: PMC4992463 DOI: 10.1002/cncr.30117] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/25/2016] [Accepted: 04/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have suggested that preoperative chemoradiation (CRT) is associated with an improved margin-negative resection rate among patients who undergo pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). However, the optimal preoperative regimen has not been established. METHODS All patients with PDAC who received chemotherapy and/or CRT followed by PD between 1999 and 2014 were retrospectively reviewed. The effects of 2 external-beam radiation regimens-a standard course of 50.4 Gy in 28 fractions and a hypofractionated course of 30 Gy in 10 fractions-were compared. Differences in clinicopathologic characteristics, locoregional recurrence (LR), and overall survival (OS) were assessed. RESULTS Among 472 patients who received preoperative therapy, 224 (47.5%) received 30 Gy, 221 (46.8%) received 50.4 Gy, and 27 (5.7%) received chemotherapy alone. Patients who received 50.4 Gy were more likely to have advanced-stage disease and to have received induction and postoperative chemotherapy, but there was no difference in the R1 margin status, treatment effect, LR, or OS between the 2 radiation groups (all P values > .05). Patients who received preoperative CRT had a lower rate of LR than patients who received preoperative chemotherapy alone (P < .01). In a multivariate Cox proportional hazards analysis, 50.4 Gy was associated with OS and LR similar to those associated with 30 Gy, whereas the absence of preoperative radiation was associated with a higher rate of LR (odds ratio, 2.21; 95% confidence interval, 1.04-4.70) and similar OS. CONCLUSIONS Preoperative hypofractionated CRT was associated with similar local control and OS in comparison with standard CRT in patients undergoing PD for PDAC. The use of chemotherapy alone without CRT was associated with poorer local control but similar survival. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2671-2679. © 2016 American Cancer Society.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Crane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sunil Krishnan
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Laura Prakash
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca A Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gauri R Varadhachary
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert A Wolff
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Milind Javle
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rachna T Shroff
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Fogelman
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Overman
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Huamin Wang
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jason B Fleming
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew HG Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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23
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Merkow J, Paniccia A, Edil BH. Laparoscopic pancreaticoduodenectomy: a descriptive and comparative review. Chin J Cancer Res 2015; 27:368-75. [PMID: 26361406 DOI: 10.3978/j.issn.1000-9604.2015.06.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/18/2015] [Indexed: 12/18/2022] Open
Abstract
Laparoscopic pancreaticoduodenectomy (LPD) is an extremely challenging surgery. First described in 1994, it has been slow to gain in popularity. Recently, however, we have seen an increase in the number of centers performing this operation, including our own institution, as well as an increase in the quantity of published data. The purpose of this review is to describe the current status of LPD as described in the literature. We performed a literature search in the PubMed database using MeSH terms "laparoscopy" and "pancreaticoduodenectomy". We then identified articles in the English language with over 20 patients that focused on LPD only. Review articles were excluded and only one article per institution was used for descriptive analysis in order to avoid overlap. There were a total of eight articles meeting review criteria, consisting of 492 patients. On descriptive analysis we found that percent of LPD due to high-grade malignancy averaged 47% over all articles. Average operative time was 452 minutes, blood loss 369 cc's, pancreatic leak rate 15%, delayed gastric emptying 8.6%, length of hospital stay 9.4 days, and short term mortality 2.3%. Comparison studies between open pancreaticoduodenectomy (OPD) and LPD suggested decreased blood loss, longer operative time, similar post-operative complication rate, decreased pain, and shorter hospital length of stay for LPD. There was also increased number of lymph nodes harvested and similar margin free resections with LPD in the majority of studies. LPD is a safe surgery, providing many of the advantages typically associated with laparoscopic procedures. We expect this operation to continue to gain in popularity as well as be offered in increasingly more complex cases. In future studies, it will be beneficial to look further at the oncologic outcome data of LPD including survival.
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Affiliation(s)
- Justin Merkow
- Department of Surgery, University Of Colorado, Aurora, USA
| | | | - Barish H Edil
- Department of Surgery, University Of Colorado, Aurora, USA
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24
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Abstract
OBJECTIVE This study aimed to evaluate the proteome of the pancreatic juice after pancreatectomy. METHODS Pancreatic juice samples were obtained during surgery and the postoperative period. Proteins were identified by mass spectrometry-based protein quantification technology and compared with published data of the nonoperated pancreas. Subgroup analyses were done in patients with pancreatic ductal adenocarcinoma (PDAC) receiving neoadjuvant chemotherapy and in smokers. RESULTS Five hundred eighteen proteins were identified in the postoperative pancreatic juice, encompassing all of the main organ functions. Sixty-seven of these were also present in the published data of the nonoperated pancreas and 7 of these had significant variation of concentration after surgery. Growth factors that have been described in postsurgical regeneration of the liver were not found to be overexpressed, whereas clusterin did, confirming the finding of previous experimental studies on pancreatic regeneration. Several proteins involved in immunomodulation and organ functions were differently expressed, depending on PDAC, neoadjuvant therapy, and smoking. CONCLUSIONS The proteome of the pancreas after surgical resection contains factors related to all main organ functions, changes over time, and is different in patients with PDAC receiving neoadjuvant therapy and in smokers. The pancreas reacts to the surgical trauma by producing proteins that protect the organ and stimulate the restoration of its function.
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Axelrod TM, Mendez BM, Abood GJ, Sinacore JM, Aranha GV, Shoup M. Peri-operative epidural may not be the preferred form of analgesia in select patients undergoing pancreaticoduodenectomy. J Surg Oncol 2014; 111:306-10. [PMID: 25363211 DOI: 10.1002/jso.23815] [Citation(s) in RCA: 20] [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] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 09/17/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Epidural analgesia has become the preferred method of pain management for major abdominal surgery. However, the superior form of analgesia for pancreaticoduodenecomy (PD), with regard to non-analgesic outcomes, has been debated. In this study, we compare outcomes of epidural and intravenous analgesia for PD and identify pre-operative factors leading to early epidural discontinuation. METHODS A retrospective review was performed on 163 patients undergoing PD between 2007 and 2011. We performed regression analyses to measure the predictive success of two groups of analgesia on morbidity and mortality and to identify predictors of epidural failure. RESULTS Intravenous analgesia alone was given to 14 (9%) patients and 149 patients (91%) received epidural analgesia alone or in conjunction with intravenous analgesia. Morbidity and mortality were not significantly different between the two groups. Early epidural discontinuation was necessary in 22 patients (15%). Those older than 72 and with a BMI < 20 (n = 5) had their epidural discontinued in 80% of cases compared to 12% not meeting these criteria. However, early epidural discontinuation was not associated with increased morbidity and mortality. CONCLUSION Epidural analgesia may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction.
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Affiliation(s)
- Trevor M Axelrod
- Department of Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, Illinois
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Adsay NV, Basturk O, Saka B, Bagci P, Ozdemir D, Balci S, Sarmiento JM, Kooby DA, Staley C, Maithel SK, Everett R, Cheng JD, Thirabanjasak D, Weaver DW. Whipple made simple for surgical pathologists: orientation, dissection, and sampling of pancreaticoduodenectomy specimens for a more practical and accurate evaluation of pancreatic, distal common bile duct, and ampullary tumors. Am J Surg Pathol 2014; 38:480-93. [PMID: 24451278 PMCID: PMC4051141 DOI: 10.1097/pas.0000000000000165] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreaticoduodenectomy (PD) specimens present a challenge for surgical pathologists because of the relative rarity of these specimens, combined with the anatomic complexity. Here, we describe our experience on the orientation, dissection, and sampling of PD specimens for a more practical and accurate evaluation of pancreatic, distal common bile duct (CBD), and ampullary tumors. For orientation of PDs, identification of the "trapezoid," created by the vascular bed at the center, the pancreatic neck margin on the left, and the uncinate margin on the right, is of outmost importance in finding all the pertinent margins of the specimen including the CBD, which is located at the upper right edge of this trapezoid. After orientation, all the margins can be sampled. We submit the uncinate margin entirely as a perpendicular inked margin because this adipose tissue-rich area often reveals subtle satellite carcinomas that are grossly invisible, and, with this approach, the number of R1 resections has doubled in our experience. Then, to ensure proper identification of all lymph nodes (LNs), we utilize the orange-peeling approach, in which the soft tissue surrounding the pancreatic head is shaved off in 7 arbitrarily defined regions, which also serve as shaved samples of the so-called "peripancreatic soft tissue" that defines pT3 in the current American Joint Committee on Cancer TNM. With this approach, our LN count increased from 6 to 14 and LN positivity rate from 50% to 73%. In addition, in 90% of pancreatic ductal adenocarcinomas there are grossly undetected microfoci of carcinoma. For determination of the primary site and the extent of the tumor, we believe bisectioning of the pancreatic head, instead of axial (transverse) slicing, is the most revealing approach. In addition, documentation of the findings in the duodenal surface of the ampulla is crucial for ampullary carcinomas and their recent site-specific categorization into 4 categories. Therefore, we probe both the CBD and the pancreatic duct from distal to the ampulla and cut the pancreatic head to the ampulla at a plane that goes through both ducts. Then, we sample the bisected pancreatic head depending on the findings of the case. For example, for proper staging of ampullary carcinomas, it is imperative to take the sections perpendicular to the duodenal serosa at the "groove" area, as ampullary carcinomas often extend to this region. Amputative (axial) sectioning of the ampulla, although good for documentation of the peri-Oddi spread of the intra-ampullary tumors, unfortunately disallows documentation of mucosal spread of the papilla of Vater tumors (those arising from the edge of the ampulla, where the ducts transition to duodenal mucosa and extending) into the neighboring duodenum. Axial sectioning also often fails to document tumor spread to the "groove" area. In conclusion, knowledge of the gross characteristics of the anatomic hallmarks is essential for proper dissection of PD specimens. The approach described above allows practical and accurate documentation and staging of pancreas, distal CBD, and ampullary cancers.
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Affiliation(s)
- N. Volkan Adsay
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Burcu Saka
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Pelin Bagci
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Denizhan Ozdemir
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Serdar Balci
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Juan M. Sarmiento
- Department of General Surgery Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - David A. Kooby
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Charles Staley
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Shishir K. Maithel
- Department of Surgical Oncology, Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | - Rhonda Everett
- Department of Pathology Emory University School of Medicine and Winship Cancer Institute Atlanta, GA
| | | | | | - Donald W. Weaver
- Department of General Surgery, Wayne State University and Karmanos Cancer Institute, Detroit, MI
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Abstract
Pancreaticoduodenectomy is one of the most challenging surgical procedures which requires the highest level of surgical expertise. This procedure has constantly evolved over the years through the meticulous efforts of a number of surgeons before reaching its current state. This review navigates through some of the early limitations and misconceptions and highlights the initial milestones which laid the foundation of this procedure. The current review also provides a few excerpts from the lives and illuminates on some of the seminal contributions of the three great surgeons: William Stewart Halsted, Walther Carl Eduard Kausch and Allen Oldfather Whipple. These surgeons pioneered the nascent stages of this procedure and paved the way for the modern day pancreaticoduodenectomy.
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Affiliation(s)
- Chandrakanth Are
- Departments of Surgery, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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28
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Abstract
BACKGROUND Minimization of blood loss during pancreatoduodenectomy requires careful surgical technique and specific preventative measures. Therefore, red blood cell (RBC) transfusions and operative time are potential surgical quality indicators. The aim of the present study was to compare peri-operative RBC transfusion and operative time with 30-day morbidity/mortality after pancreatoduodenectomy. METHODS All pancreatoduodenectomies (2005 to 2008) were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). RBC transfusions and operative time were correlated with 30-day morbidity/mortality. RESULTS Pancreatoduodenectomy was completed in 4817 patients. RBC transfusions were given to 1559 (32%) patients (1-35 units). Overall morbidity and mortality rates were 37% and 3.0%, respectively. Overall 30-day morbidity increased in a stepwise manner with the number of RBC transfusions (R = 0.69, P < 0.01). Although RBC transfusions and operative times were not statistically linked (P = 0.87), longer operative times were linearly associated with increased 30-day morbidity (R = 0.79, P < 0.001) and mortality (R = 0.65, P < 0.01). Patients who were not transfused also displayed less morbidity (33%) and mortality (1.9%) (P < 0.05). DISCUSSION Peri-operative RBC transfusion after pancreatoduodenectomy is linearly associated with 30-day morbidity. Longer operative time also correlates with increased morbidity and mortality. Therefore, blood transfusions and prolonged operative time should be considered quality indicators for pancreatoduodenectomy.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana UniversityIndianapolis, IN, USA
| | - Henry A Pitt
- Department of Surgery, Indiana UniversityIndianapolis, IN, USA
| | - Molly E Kilbane
- Department of Surgery, Indiana UniversityIndianapolis, IN, USA
| | - Elijah Dixon
- Department of Surgery, University of CalgaryCalgary, Canada
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Khalifa MA, Maksymov V, Rowsell CH, Hanna S. A novel approach to the intraoperative assessment of the uncinate margin of the pancreaticoduodenectomy specimen. HPB (Oxford) 2007; 9:146-9. [PMID: 18333131 PMCID: PMC2020790 DOI: 10.1080/13651820701278273] [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] [Received: 12/18/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Currently, there is no consensus regarding the pancreaticoduodenectomy (PD) margins examined intraoperatively or the technical protocol for frozen section examination. The aim of this work was to summarize our experience regarding the intraoperative examination of the uncinate margin and to compare it with the published literature. MATERIALS AND METHODS Our local protocol for the intraoperative assessment of the uncinate margin of the PD specimen is described in this article. A PubMed search limited to English language publications using terms along the theme of pancreaticoduodenectomy and margin was performed. Retrieved articles were categorized according to whether they discussed frozen section margin examination. RESULTS Ten articles published between 1981 and 2005 were retrieved which discussed the intraoperative examination of PD specimens. Of the 10 articles, 5 discussed the intraoperative consultation for diagnostic purposes only, 2 discussed the consultation for both diagnostic purposes and assessment of margins, and 3 discussed intraoperative assessment of margins only. Of the total of five articles that discussed the intraoperative assessment of margins, none detailed the technical protocol for examining the uncinate margin. DISCUSSION Our proposed protocol for the intraoperative assessment of the uncinate margin of PD specimens allows for its accurate evaluation and has not been described previously in the English literature.
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Affiliation(s)
- Mahmoud A. Khalifa
- Departments of Pathology, Sunnybrook Health Sciences CenterTorontoCanada
| | - Vlad Maksymov
- Departments of Pathology, Sunnybrook Health Sciences CenterTorontoCanada
| | - Corwyn H. Rowsell
- Departments of Pathology, Sunnybrook Health Sciences CenterTorontoCanada
| | - Sherif Hanna
- Surgical Oncology, Sunnybrook Health Sciences CenterTorontoCanada
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