Major postoperative complications increase tumor recurrence rate and diminish long-term survival following resection for pancreatic ductal adenocarcinoma

Objective

Major complications have been associated with worse oncologic outcomes following resection for several gastrointestinal malignancies. However, the impact of major postoperative morbidity on the survival of patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.

Methods

Clinicopathological data of patients who underwent resection for PDAC between 2014 and 2019 in a major swiss hepatopancreatobiliary center were assessed. We evaluated the disease-free (DFS) and overall survival (OS) of patients suffering a major postoperative complication (grade-3 or higher within 90 days according to Clavien-Dindo classification) in comparison to those of patients without any major postoperative adverse events.

Results

During the study period, 186 patients underwent resection for PDAC with curative intent. Pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy were performed in 66%, 12%, and 22% of patients, respectively. Major 90-day postoperative morbidity and mortality rate were 21.5% and 4.3%, respectively. After excluding patients who died within 90 days, major postoperative morbidity significantly increased the length of hospital stay [median 22 (8-66) days vs. 13 (5-26) days, p < 0.0001] resulting in a delay of returning to intended oncologic treatment and reducing the likelihood of receiving adjuvant chemotherapy (56% vs. 83%, p = 0.001). Postoperative major complications were associated with significantly worse DFS (median DFS 10 vs. 16 months, hazard ratio 1.9, 95% confidence interval 1.91-2.96, p = 0.004) and worse OS (median OS 14 vs. 37 months, hazard ratio 1.7, 95% confidence interval 1.02-2.75, p = 0.04) in multivariate analysis.

Conclusion

Major postoperative complications promote tumor recurrence following resection for PDAC, thus limiting long-term survival. Careful patient selection and optimized complication management may reduce postoperative morbidity, thereby lowering its negative impact on oncologic prognosis.

Endoscopic ultrasound-guided hepaticogastrostomy vs. ERCP for preoperative biliary drainage in patients undergoing pancreatic resection

Objective

Preoperative bile drainage in patients with obstructive jaundice due to pancreatic head malignancy is needed, if pancreatic head resection cannot be performed in a timely fashion. The safety and efficacy of ultrasound-guided hepaticogastrostomy (HGS) as an alternative to the established endoscopic retrograde cholangio-pancreatography (ERCP) with stent placement needs further investigation.

Methods

Clinicopathological data of patients who underwent partial or total pancreaticoduodenectomy between January 2017 and December 2019 in a major swiss hepatopancreatobiliary center were assessed. We compared the HGS with ERCP/stent regarding the kinetics of bilirubin decrease, the procedure-related morbidity, and the postoperative surgical outcomes.

Results

During the study period, 102 patients underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic malignancy. Preoperative bile drainage was performed in 65 patients (20 HGS, 45 ERCP). HGS was associated with a faster (6 vs. 10 days, P = 0.042) and more effective (133 µmol/L vs. 101 µmol/L, P = 0.037) reduction of the serum bilirubin levels. HGS was safe and did not differ from ERCP with stent placement concerning post-interventional complications (P = 0.565), postoperative mortality (P = 0.996) and postoperative morbidity (P = 0.896), including infectious complications (wound infection, P = 0.662/ intra-abdominal abscess, P = 0.587), severe pancreatic fistula (P = 0.587), bile leak (P = 0.131), and postoperative hemorrhage (P = 0.886).

Conclusion

HGS performed in a specialized multidisciplinary hepatopancreatobiliary center is feasible and safe and may result in more accelerated and effective bile drainage compared to the established ERCP. In patients with obstructive jaundice related to pancreatic malignancy unable to undergo adequate bile drainage by ERCP, HGS may be an effective alternative method enabling surgery in a timely manner.

Truncular vascular malformations in a varicose vein surgery patient cohort

BACKGROUND

To determine the incidence and significance of vascular malformations in a varicose vein surgery patient cohort in a prospective cohort study.

PATIENTS AND METHODS

During a ten year time span we prospectively searched for patients with vascular malformations within a varicose vein surgery cohort. All patients underwent colour duplex sonography and surgery for symptomatic chronic venous disease or chronic venous insufficiency corresponding to clinical classes C2 to C6 according to CEAP.

RESULTS

Five out of 1488 patients had truncular vascular malformations. One patient had an arterio-venous malformation in the groin. Venous malformations were found in three marginal veins and one bone perforating vein. Two of these five patients had a mitral valve prolapse syndrome, one a persistent foramen ovale, one had a bone cyst in a finger and one ectromelia of the hands and feet, respectively. No complications occurred following surgical treatment of these five malformations.

CONCLUSIONS

Truncular arterio-venous and venous malformations in a varicose vein surgery patient cohort are rare. In our cohort the hemodynamic impact of the vascular malformations was low, the surgical treatment combined with varicose vein surgery resulted in technical and clinical success.

TRP channels in lymphocytes

TRP proteins form ion channels that are activated following receptor stimulation. Several members of the TRP family are likely to be expressed in lymphocytes. However, in many studies, messenger RNA (mRNA) but not protein expression was analyzed and cell lines but not primary human or murine lymphocytes were used. Among the expressed TRP mRNAs are TRPC1, TRPC3, TRPM2, TRPM4, TRPM7, TRPV1, and TRPV2. Regulation of Ca2+ entry is a key process for lymphocyte activation, and TRP channels may both increase Ca2+ influx (such as TRPC3) or decrease Ca2+ influx through membrane depolarization (such as TRPM4). In the future, linking endogenous Ca2+/cation channels in lymphocytes with TRP proteins should lead to a better molecular understanding of lymphocyte activation.

Effect of unilateral pulmonary artery occlusion on the arterial oxygen pressure of children undergoing pulmonary systemic artery shunt procedures

Of 20 children undergoing thoracotomy who had blood-gas analysis at various intervals during their operative procedure, 18 had congenital heart disease causing cyanosis. The venous admixture was apparent on compressing the lung to expose the mediastinal structures and was diminished upon clamping the pulmonary artery to the exposed lung. This observation may be of clinical value in raising the arterial oxygen pressure when sudden deterioration occurs during performance of a systemic pulmonary shunt in cyanotic children.