Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel

BACKGROUND

We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic.

METHODS

Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).

RESULTS

The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland.

CONCLUSION

The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise.

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

BACKGROUND

It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD).

METHODS

A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and χ(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression.

RESULTS

Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003).

CONCLUSION

There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

Transarterial embolization therapies for the treatment of hepatocellular carcinoma: CEPO review and clinical recommendations

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most deadly cancers in the world and its incidence rate has consistently increased over the past 15 years in Canada. Although transarterial embolization therapies are palliative options commonly used for the treatment of HCC, their efficacy is still controversial. The objective of this guideline is to review the efficacy and safety of transarterial embolization therapies for the treatment of HCC and to develop evidence-based recommendations.

METHOD

A review of the scientific literature published up to October 2013 was performed. A total of 38 studies were included.

RECOMMENDATIONS

Considering the evidence available to date, the CEPO recommends the following: (i) transarterial chemoembolization therapy (TACE) be considered a standard of practice for the palliative treatment of HCC in eligible patients; (ii) drug-eluting beads (DEB)-TACE be considered an alternative and equivalent treatment to conventional TACE in terms of oncological efficacy (overall survival) and incidence of severe toxicities; (iii) the decision to treat with TACE or DEB-TACE be discussed in tumour boards; (iv) bland embolization (TAE) not be considered for the treatment of HCC; (v) radioembolization (TARE) not be considered outside of a clinical trial setting; and (vi) sorafenib combined with TACE not be considered outside of a clinical trial setting.

Adjuvant treatment for endometrial cancer: literature review and recommendations by the Comité de l'évolution des pratiques en oncologie (CEPO)

OBJECTIVE

Despite the very good prognosis of endometrial cancer, a number of patients with localized disease relapse following surgery. Therefore, various adjuvant therapeutic approaches have been studied. The objective of this review is to evaluate the efficacy and safety of neoadjuvant and adjuvant therapies in patients with resectable endometrial cancer and to develop evidence-based recommendations.

METHODS

A review of the scientific literature published between January 1990 and June 2012 was performed. The search was limited to published phase III clinical trials and meta-analyses evaluating the efficacy of neoadjuvant or adjuvant therapies in patients with endometrial carcinoma or carcinosarcoma. A total of 23 studies and five meta-analyses were identified.

RESULTS

The selected literature showed that in patients with a low risk of recurrence, post-surgical observation is safe and recommended in most cases. There are several therapeutic modalities available for treatment of endometrial cancers with higher risk of recurrence, including vaginal brachytherapy, external beam radiotherapy, chemotherapy, or a combination of these.

CONCLUSIONS

Considering the evidence available to date, the CEPO recommends the following: (1)post-surgical observation for most patients with a low recurrence risk; (2)adjuvant vaginal brachytherapy for patients with an intermediate recurrence risk; (3)adjuvant pelvic radiotherapy with or without vaginal brachytherapy for patients with a high recurrence risk; addition of adjuvant chemotherapy may be considered as an option for selected patients (excellent functional status, no significant co-morbidities, poor prognostic factors); (4)adjuvant chemotherapy and pelvic radiotherapy with or without brachytherapy and para-aortic irradiation for patients with advanced disease;

The body size-dependent diet composition of north american sea ducks in winter

Daily food requirements scale with body mass and activity in animals. While small species of birds have higher mass-specific field metabolic rates than larger species, larger species have higher absolute energy costs. Under energy balance, we thus expect the small species to have a higher energy value diet. Also the weight and time constraints for flighted and diurnal foragers should set a maximum to the amount of prey items taken in one meal and to the daily number of meals, respectively. Further, avoidance of competition causes the species to reduce the amount of shared prey in their diet. Some diet segregation is therefore to be expected between species. We tested these hypotheses and investigated the role of body mass in the diet composition of 12 sea duck species (Somateria mollissima, Somateria spectabilis, Somateria fischeri, Polysticta stelleri, Bucephala clangula, Bucephala islandica, Bucephala albeola, Melanitta nigra, Melanitta perspicillata, Melanitta deglandi, Histrionicus histrionicus and Clangula hyemalis) wintering in North America. This study was based on a literature survey with special emphasis given to the diet data from the former US Bureau of Biological Survey. The data supported our hypothesis that the energy value of winter diet of sea ducks scales negatively with body mass. Diet diversity also scaled negatively with body mass. Our results suggest the existence of a minimum for the energy value of avian diets.

Metals, trace elements, polychlorinated biphenyls, organochlorine pesticides, and brominated flame retardants in tissues of Barrow's goldeneyes (Bucephala islandica) wintering in the St. Lawrence marine ecosystem, eastern Canada

The eastern North American population of Barrow's goldeneyes winters in the St. Lawrence Estuary and Gulf of St. Lawrence where the sediments and food web are known to be contaminated with inorganic and organic compounds. Therefore, there is a potential for contamination of this population, which is designated of Special Concern by the Committee on the Status of Endangered Wildlife in Canada. Specimens were collected during three consecutive winters (2005-2007) in three regions (Manicouagan, Charlevoix, and Chaleur Bay) and analysed for metals, trace elements, polychlorinated biphenyls (PCBs), organochlorine pesticides, and brominated flame retardants (BFRs). Liver mercury levels were greater in the St. Lawrence Estuary (4.4 mg/kg in Manicouagan, 3.8 mg/kg in Charlevoix) than in Chaleur (2.4 mg/kg), whereas selenium showed the opposite pattern (7.3 mg/kg in Manicouagan, 7.0 mg/kg in Charlevoix, and 36.9 mg/kg in Chaleur). Liver PCB levels were greater in specimens from Manicouagan (236 ng/g) than in those from the two other regions (72 ng/g in Charlevoix, 35 ng/g in Chaleur). DDT was greater in Chaleur (66 ng/g) versus 10 ng/g in Manicouagan and 16 ng/g in Charlevoix. BFRs were not compared among regions because of smaller sample sizes, but mean total concentration was low (4.02 ng/g). Overall, although significant differences were found across regions, levels of all contaminants measured are generally low and not of toxicological concern for this population.

Consensus recommendations for the diagnosis and management of well-differentiated gastroenterohepatic neuroendocrine tumours: a revised statement from a Canadian National Expert Group

Well-differentiated neuroendocrine tumours (nets-previously called "carcinoid tumours") are relatively rare tumours originating from the diffuse neuroendocrine system; they are found most often in the bronchial or gastrointestinal systems. In Canada, gastroenterohepatic NETS represent less than 0.25% of oncology cases. Because of the relative rarity of these tumours, diagnostic and therapeutic approaches vary and are often based on individual physician experience. A number of European and North American groups have developed consensus guidelines for the diagnosis and management of well-differentiated gastroenterohepatic NETS, and in 2006, Canadian consensus guidelines were published by a Canadian expert group. The updated and expanded current Canadian guidelines are based on a consensus meeting held in Paris, France, in 2008 and are based on the most current literature.

Spatial distribution and habitat selection of Barrow’s and Common goldeneyes wintering in the St. Lawrence marine system

Our study addresses winter spatial distribution of Barrow’s Goldeneyes ( Bucephala islandica (Gmelin, 1789)) and Common Goldeneyes ( Bucephala clangula (L., 1758)) at the scale of the St. Lawrence marine system (estuary and northwestern gulf), eastern Canada. Our objectives were (i) to identify and compare the physical factors that control their distributions, (ii) to quantify the level of sympatry between the two species, and (iii) to compare their distribution patterns. We analyzed large-scale synoptic views of winter distribution of both goldeneye species obtained through helicopter-borne surveys. Habitat description was obtained through spatial analyses and remote sensing. Both species showed strong preference for the tidal zone and river mouths. A multiscale analysis showed a decreasing level of sympatry as spatial resolution was refined. The distribution of the Barrow’s Goldeneye was more clustered compared with that of the Common Goldeneye, and Barrow’s Goldeneye was repeatedly observed in the same few areas. A use-availability analysis identified the northern coast of the St. Lawrence estuary as the main wintering ground for Barrow’s Goldeneye in eastern North America.

[Clinical practice guideline on peritoneal carcinomatosis treatment using surgical cytoreduction and hyperthermic intraoperative intraperitoneal chemotherapy]

In 2005, the Comité de l'évolution des pratiques en oncologie (CEPO) took it upon itself to develop a clinical practice guideline to determine the clinical value of surgical cytoreduction followed by hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for treating peritoneal carcinomatosis stemming from colorectal cancer, cancers of the appendix and stomach, pseudomyxoma peritonei, and mesothelioma of the peritoneum. A review of the scientific literature was performed using the PubMed search engine. The period covered extended from January 1990 to January 2006, inclusively. The scientific literature search was limited to clinical trials (minimum phase II) and organizations elaborating clinical practice recommendations. Twenty-six studies were identified. Of these, only one was phase III. Although some of these studies have demonstrated a benefit from this treatment in terms of patient survival, HIPEC remains a complex procedure whose optimal use is uncertain. Given the morbidity and mortality associated with this treatment, this procedure requires a high level of expertise. Considering the evidence available, the CEPO recommends: 1) that complete cytoreduction followed by HIPEC be used in a clinical research context only, preferably in the presence of an isolated peritoneal carcinomatosis stemming from colorectal cancer, cancer of the appendix, peritoneal pseudomyxoma, or mesothelioma of the peritoneum; 2) that studies be conducted only in specialized centers with the necessary expertise and technical resources.

Risk factors for mortality and morbidity after elective sigmoid resection for diverticulitis: prospective multicenter multivariate analysis of 582 patients

The prevalence of diverticular disease of the colon is increasing in occidental countries. It would be useful to further decrease the mortality and morbidity after elective sigmoid resection (ESR) for diverticulitis. The aim of this study was to identify modifiable preoperative and intraoperative risk factors for mortality and morbidity after ESR for diverticulitis. A database of 2615 patients who underwent a colon or rectal resection with primary anastomosis between 1985 to 1998 has been constructed from prospective randomized studies published by a French surgical group. Of those patients, 582 had undergone ESR for diverticulitis, and they constitute the population of the present study. A total of 46 potential preoperative and intraoperative risk factors for mortality and morbidity have been studied by univariate and multivariate analysis. The operative mortality for our series was 1.2%, and the overall morbidity was 24.9%. The multivariate analysis revealed two statistically significant independent risk factors of mortality: age >75 (odds-ratio=7.9; 95% confidence interval [CI 1.7-36.6]; p=0.01) and obesity (odds-ratio=5.2; 95% CI [1.1-27.9]; p=0.04). The abdominal morbidity (AM) was 6.5% (38/582). The absence of antimicrobial prophylaxis administration with ceftriaxone was the only significant risk factor for AM in multivariate analysis (p=0.003; odds-ratio=2; 95% CI [1.1-4]). The extraabdominal morbidity (EAM) was 18.4% (107/582). Both chronic pulmonary disease (p=0.008; odds-ratio=2.9; 95% CI [1.4-6]; p=0.008) and cirrhosis (odds-ratio=12; 95% CI [1.2-120]) proved to be significant risk factors for EAM. Weight control prior to surgery, routine administration of prophylactic preoperative antibiotics, and preoperative optimization of the respiratory status of patients with chronic pulmonary disease could decrease the postoperative mortality and morbidity associated with ESR for diverticulitis.

Incidence, distribution, and significance of hilar lymph node metastases in hepatic colorectal metastases

For many surgeons, the presence of HLNM has been a formal contraindication to resection of LM from colorectal cancer. This attitude is based on the very poor survival seen in small subgroups of patients with HLNM who have been included in large-scale studies of patients with LM. The incidence of macroscopic HLNM in patients with LM has been reported at 1% to 12%. In the authors' experience, the rate of macroscopic HLNM is 7% and the incidence of macroscopic and microscopic HLNM is 19%. The reported 5-year survival rate of patients with resected HLNM is generally poor (12%), although this article reports a study with a 5-year overall survival rate of 27%. The authors do not recommend routine hilar lymph node biopsy and frozen section for all patients with LM undergoing resection; however, they do recommend a systematic palpation of hepatoduodenal lymph nodes with frozen section of suspicious lymphadenopathy prior to resection. In cases of proven HLNM, combined liver resection and lymphadenectomy could be considered in selected patients. This selection should be performed on an individual basis guided by the absence of important comorbid condition, the biology of the disease, and the surgeon's judgment that this is limited hilar lymphatic involvement without other sites of extrahepatic disease. Systematic routine en bloc lymphadenectomy currently has no prognostic value and no known therapeutic effects.

Heated intra-operative intraperitoneal oxaliplatin after complete resection of peritoneal carcinomatosis: pharmacokinetics and tissue distribution

PURPOSE

This article reports the pharmacokinetics (PK) of heated intra-operative intraperitoneal oxaliplatin and its tolerance profile. Oxaliplatin has demonstrated significant activity in advanced colorectal cancer, and this is the first publication concerning its intraperitoneal administration.

METHODS

Twenty consecutive patients with peritoneal carcinomatosis (PC) of either gastrointestinal or uniquely peritoneal origin underwent complete cytoreductive surgery followed by intra-operative intraperitoneal chemo-hyperthermia (IPCH) with increasing doses of oxaliplatin. We performed IPCH using an open procedure (skin pulled upwards), at an intraperitoneal temperature of 42-44 degrees C, with 2 l/m2 of 5% dextrose instillate in a closed circuit. The flow-rate was 2 l/min for 30 min. Patients received intravenous leucovorin (20 mg/m2) and 5-fluorouracil (400 mg/m2) just before the IPCH to maximize the effect of oxaliplatin. We treated at least three patients at each of the six intraperitoneal oxaliplatin dose levels (from 260 to 460 mg/m2) before progressing to the next. We analysed intraperitoneal, plasma and tissue samples with atomic absorption spectrophotometry.

RESULTS

The mean duration of the entire procedure was 8.4 +/- 2.7 h. Half the oxaliplatin dose was absorbed in 30 min at all dose levels. Area under the curve (AUC) and maximal plasma concentration (Cmax) increased with dose. At the highest dose level (460 mg/m2), peritoneal oxaliplatin concentration was 25-fold that in plasma. AUCs following intraperitoneal administration were consistently inferior to historical control AUCs after intravenous oxaliplatin (130 mg/m2). Intratumoral oxaliplatin penetration was high, similar to absorption at the peritoneal surface and 17.8-fold higher than that in non-bathed tissues. Increasing instillate volume to 2.5 l/m2 instead of 2 l/m2 dramatically decreased oxaliplatin concentration and absorption. There were no deaths, nor severe haematological, renal or neurological toxicity, but we observed two fistulas and three deep abscesses.

CONCLUSIONS

Heated intraperitoneal chemotherapy gives high peritoneal and tumour oxaliplatin concentrations with limited systemic absorption. We recommend an oxaliplatin dose of 460 mg/m2 in 2 l/m2 of 5% dextrose for intraperitoneal chemo-hyperthermia, at a temperature of 42-44 degrees C over 30 min. We may be able to improve these results by increasing the intraperitoneal perfusion duration or by modifying the instillate composition.

Percutaneous radiofrequency thermoablation as an alternative to surgery for treatment of liver tumour recurrence after hepatectomy

BACKGROUND

Radiofrequency (RF) current, converted into heat through ion agitation and friction, can destroy liver tumours by means of coagulation necrosis. This study assessed whether percutaneous RF ablation is a useful and safe technique for the treatment of liver tumour recurrence after hepatectomy.

METHODS

Forty-seven patients presenting with local recurrence after hepatectomy for malignant tumours (29 with colorectal secondaries) were treated with percutaneous RF ablation instead of repeat hepatectomy. RF thermal ablation was performed under image guidance for 12-15 min. This group represented 63 per cent of 75 patients treated with curative intent for liver recurrence in the same time interval. The other 28 patients underwent repeat hepatectomy.

RESULTS

The mean(s.d.) number of liver metastases destroyed was 1.4(0.7) (range 1-3) and their diameter was 21(8) (range 9-35) mm. Twenty-six patients presented with liver recurrence at least once but up to three times after the initial RF application. Incomplete local RF treatment was observed in six of 47 patients. Fifteen patients developed extrahepatic recurrence. The mean(s.d.) interval between RF ablation and the last follow-up visit was 14.4(10.1) (range 5.5-40) months. One death and three major complications occurred. Survival rates at 1 and 2 years were 88 and 55 per cent respectively. A retrospective study of the authors' database over two similar consecutive periods showed that RF ablation increased the percentage of curative local treatments for liver recurrence after hepatectomy from 17 to 26 per cent and decreased the proportion of repeat hepatectomies from 100 to to 39 per cent.

CONCLUSION

Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails.

Heated intra-operative intraperitoneal oxaliplatin after complete resection of peritoneal carcinomatosis: pharmacokinetics and tissue distribution

PURPOSE

This article reports the pharmacokinetics (PK) of heated intra-operative intraperitoneal oxaliplatin and its tolerance profile. Oxaliplatin has demonstrated significant activity in advanced colorectal cancer, and this is the first publication concerning its intraperitoneal administration.

METHODS

Twenty consecutive patients with peritoneal carcinomatosis (PC) of either gastrointestinal or uniquely peritoneal origin underwent complete cytoreductive surgery followed by intra-operative intraperitoneal chemo-hyperthermia (IPCH) with increasing doses of oxaliplatin. We performed IPCH using an open procedure (skin pulled upwards), at an intraperitoneal temperature of 42-44 degrees C, with 2 l/m2 of 5% dextrose instillate in a closed circuit. The flow-rate was 2 l/min for 30 min. Patients received intravenous leucovorin (20 mg/m2) and 5-fluorouracil (400 mg/m2) just before the IPCH to maximize the effect of oxaliplatin. We treated at least three patients at each of the six intraperitoneal oxaliplatin dose levels (from 260 to 460 mg/m2) before progressing to the next. We analysed intraperitoneal, plasma and tissue samples with atomic absorption spectrophotometry.

RESULTS

The mean duration of the entire procedure was 8.4 +/- 2.7 h. Half the oxaliplatin dose was absorbed in 30 min at all dose levels. Area under the curve (AUC) and maximal plasma concentration (Cmax) increased with dose. At the highest dose level (460 mg/m2), peritoneal oxaliplatin concentration was 25-fold that in plasma. AUCs following intraperitoneal administration were consistently inferior to historical control AUCs after intravenous oxaliplatin (130 mg/m2). Intratumoral oxaliplatin penetration was high, similar to absorption at the peritoneal surface and 17.8-fold higher than that in non-bathed tissues. Increasing instillate volume to 2.5 l/m2 instead of 2 l/m2 dramatically decreased oxaliplatin concentration and absorption. There were no deaths, nor severe haematological, renal or neurological toxicity, but we observed two fistulas and three deep abscesses.

CONCLUSIONS

Heated intraperitoneal chemotherapy gives high peritoneal and tumour oxaliplatin concentrations with limited systemic absorption. We recommend an oxaliplatin dose of 460 mg/m2 in 2 l/m2 of 5% dextrose for intraperitoneal chemo-hyperthermia, at a temperature of 42-44 degrees C over 30 min. We may be able to improve these results by increasing the intraperitoneal perfusion duration or by modifying the instillate composition.

Intraperitoneal chemohyperthermia: rationale, technique, indications, and results

Intraperitoneal chemohyperthermia (IPCH) is a loco-regional treatment for intraperitoneal malignancies. This ultra-radical treatment combines complete cytoreduction of macroscopic peritoneal disease preceding perioperative intraperitoneal perfusion of a chemotherapeutic drug heated to 42 degrees to 44 degrees to treat microscopic residual disease. At present time, this approach is mainly indicated for isolated limited peritoneal carcinomatosis (PC) of colorectal origin and for treatment of low-grade pseudomyxoma peritonei. In selected patients, IPCH may lead to 27% five-year overall survival in cases of PC, and as high as 86% five-year survival in cases of pseudomyxoma peritonei. In the near future, this approach will become the standard treatment for selected cases of PC.