1
|
van Bodegraven EA, Balduzzi A, van Ramshorst TME, Malleo G, Vissers FL, van Hilst J, Festen S, Abu Hilal M, Asbun HJ, Michiels N, Koerkamp BG, Busch ORC, Daams F, Luyer MDP, Ramera M, Marchegiani G, Klaase JM, Molenaar IQ, de Pastena M, Lionetto G, Vacca PG, van Santvoort HC, Stommel MWJ, Lips DJ, Coolsen MME, Mieog JSD, Salvia R, van Eijck CHJ, Besselink MG. Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet Gastroenterol Hepatol 2024; 9:438-447. [PMID: 38499019 DOI: 10.1016/s2468-1253(24)00037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Prophylactic passive abdominal drainage is standard practice after distal pancreatectomy. This approach aims to mitigate the consequences of postoperative pancreatic fistula (POPF) but its added value, especially in patients at low risk of POPF, is currently being debated. We aimed to assess the non-inferiority of a no-drain policy in patients after distal pancreatectomy. METHODS In this international, multicentre, open-label, randomised controlled, non-inferiority trial, we recruited patients aged 18 years or older undergoing open or minimally invasive elective distal pancreatectomy for all indications in 12 centres in the Netherlands and Italy. We excluded patients with an American Society of Anesthesiology (ASA) physical status of 4-5 or WHO performance status of 3-4, added by amendment following the death of a patient with ASA 4 due to a pre-existing cardiac condition. Patients were randomly assigned (1:1) intraoperatively by permuted blocks (size four to eight) to either no drain or prophylactic passive drain placement, stratified by annual centre volume (<40 or ≥40 distal pancreatectomies) and low risk or high risk of grade B or C POPF. High-risk was defined as a pancreatic duct of more than 3 mm in diameter, a pancreatic thickness at the neck of more than 19 mm, or both, based on the Distal Pancreatectomy Fistula Risk Score. Other patients were considered low-risk. The primary outcome was the rate of major morbidity (Clavien-Dindo score ≥III), and the most relevant secondary outcome was grade B or C POPF, grading per the International Study Group for Pancreatic Surgery. Outcomes were assessed up to 90 days postoperatively and analysed in the intention-to-treat population and per-protocol population, which only included patients who received the allocated treatment. A prespecified non-inferiority margin of 8% was compared with the upper limit of the two-sided 95% CI (Wald) of unadjusted risk difference to assess non-inferiority. This trial is closed and registered in the Netherlands Trial Registry, NL9116. FINDINGS Between Oct 3, 2020, and April 28, 2023, 376 patients were screened for eligibility and 282 patients were randomly assigned to the no-drain group (n=138; 75 [54%] women and 63 [46%] men) or the drain group (n=144; 73 [51%] women and 71 [49%] men). Seven patients in the no-drain group received a drain intraoperatively; consequently, the per-protocol population included 131 patients in the no-drain group and 144 patients in the drain group. The rate of major morbidity was non-inferior in the no-drain group compared with the drain group in the intention-to-treat analysis (21 [15%] vs 29 [20%]; risk difference -4·9 percentage points [95% CI -13·8 to 4·0]; pnon-inferiority=0·0022) and the per-protocol analysis (21 [16%] vs 29 [20%]; risk difference -4·1 percentage points [-13·2 to 5·0]; pnon-inferiority=0·0045). Grade B or C POPF was observed in 16 (12%) patients in the no-drain group and in 39 (27%) patients in the drain group (risk difference -15·5 percentage points [95% CI -24·5 to -6·5]; pnon-inferiority<0·0001) in the intention-to-treat analysis. Three patients in the no-drain group died within 90 days; the cause of death in two was not considered related to the trial. The third death was a patient with an ASA score of 4 who died after sepsis and a watershed cerebral infarction at second admission, leading to multiple organ failure. No patients in the drain group died within 90 days. INTERPRETATION A no-drain policy is safe in terms of major morbidity and reduced the detection of grade B or C POPF, and should be the new standard approach in eligible patients undergoing distal pancreatectomy. FUNDING Ethicon UK (Johnson & Johnson Medical, Edinburgh, UK).
Collapse
Affiliation(s)
- Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Alberto Balduzzi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Tess M E van Ramshorst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Giuseppe Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Surgery, OLVG, Amsterdam, Netherlands
| | | | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Olivier R C Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Marco Ramera
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy; Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, Netherlands
| | - Matteo de Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Gabriella Lionetto
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Casper H J van Eijck
- Department of Surgery and Pulmonology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands.
| |
Collapse
|
2
|
Bannone E, Pulvirenti A, Marchegiani G, Vacca PG, Marchetti A, Cattelani A, Salvia R, Bassi C. No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis. Pancreatology 2023; 23:904-910. [PMID: 37839921 DOI: 10.1016/j.pan.2023.09.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD). METHODS Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias. RESULTS Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.
Collapse
Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy; Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy. https://twitter.com/PancreasVerona
| | - Alessandra Pulvirenti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessio Marchetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| |
Collapse
|
3
|
Paiella S, Azzolina D, Trestini I, Malleo G, Nappo G, Ricci C, Ingaldi C, Vacca PG, De Pastena M, Secchettin E, Zamboni G, Maggino L, Corciulo MA, Sandini M, Cereda M, Capretti G, Casadei R, Bassi C, Mansueto G, Gregori D, Milella M, Zerbi A, Gianotti L, Salvia R. Corrigendum: Body composition parameters, immunonutritional indexes, and surgical outcome of pancreatic cancer patients resected after neoadjuvant therapy: a retrospective, multicenter analysis. Front Nutr 2023; 10:1212436. [PMID: 37284653 PMCID: PMC10240154 DOI: 10.3389/fnut.2023.1212436] [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: 04/26/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
[This corrects the article DOI: 10.3389/fnut.2023.1065294.].
Collapse
Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Ilaria Trestini
- Dietetics Services, Hospital Medical Direction, University Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Ricci
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pier Giuseppe Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giulia Zamboni
- Radiology Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Maggino
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Maria Assunta Corciulo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marta Sandini
- General Surgery Unit, University of Siena, Siena, Italy
| | - Marco Cereda
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| |
Collapse
|
4
|
Bannone E, Marchegiani G, Zamboni GA, Maris BM, Costa L, Procida G, Vacca PG, D'Onofrio M, Mansueto G, De-Madaria E, Salvia R, Bassi C. Acute pancreatitis after pancreatoduodenectomy: A prospective study of diffusion-weighted magnetic resonance imaging, serum biomarkers, and clinical features. Surgery 2023; 173:1428-1437. [PMID: 36935293 DOI: 10.1016/j.surg.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/13/2023] [Accepted: 02/07/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Postpancreatectomy acute pancreatitis is challenging to diagnose and poorly characterized in its early phases. However, it represents the ideal target for novel therapeutic opportunities possibly gleaned from medical acute pancreatitis. This study aims to systematically investigate early radiologic, biochemical, and clinical features of postpancreatectomy acute pancreatitis. METHODS This was a prospective observational study of patients undergoing pancreatoduodenectomy from September 2019 to January 2021. Diffusion-weighted magnetic resonance imaging was performed on postoperative day 3. Serum pancreatic amylase and lipase were assessed daily until postoperative day 5. Postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis were defined based on the International Study Group for Pancreatic Surgery definition. RESULTS A total of 65 patients were enrolled according to the sample size calculation. Patients with postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis had significantly lower apparent diffusion coefficient values at diffusion-weighted magnetic resonance imaging but no macroscopic features consistent with acute pancreatitis. Subsequently, 21 patients (32.3%) underwent computed tomography imaging for clinical worsening, and 6 had radiologic features of acute pancreatitis. All these latter patients had postoperative serum hyperamylasemia and worse outcomes, characterized by local (postoperative pancreatic fistula: 83%) and systemic morbidity (sepsis: 66.7%). The postoperative serum hyperamylasemia incidence was 21.5% (n = 14), and postpancreatectomy acute pancreatitis occurred in 6 patients (9.2%), with 4 grade B (6.1%) and 2 grade C (3%). CONCLUSION Postpancreatectomy acute pancreatitis is characterized by early serum hyperamylasemia and hyperlipasemia. Although pancreatic changes may appear at postoperative day 3 diffusion-weighted magnetic resonance imaging, its standard use has no impact on postoperative management. Macroscopic radiologic features appear later and correlate with worse clinical scenarios. This paper paves the ground for including postpancreatectomy acute pancreatitis in the spectrum of acute pancreatitis, promoting the transfer of treatment strategies for acute pancreatitis into managing postpancreatectomy acute pancreatitis.
Collapse
Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy; Department of General Surgery, Poliambulanza Hospital, Brescia, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giulia Angela Zamboni
- Department of Radiology, G.B. Rossi Hospital, University of Verona Hospital Trust, Italy
| | - Bogdan Mihai Maris
- Department of Computer Science, University of Verona Hospital Trust, Italy
| | - Lorenzo Costa
- Department of Radiology, G.B. Rossi Hospital, University of Verona Hospital Trust, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy; Department of Computer Science, University of Verona Hospital Trust, Italy
| | - Mirko D'Onofrio
- Department of Radiology, G.B. Rossi Hospital, University of Verona Hospital Trust, Italy
| | - Giancarlo Mansueto
- Department of Radiology, G.B. Rossi Hospital, University of Verona Hospital Trust, Italy
| | - Enrique De-Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Spain
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Italy.
| |
Collapse
|
5
|
Paiella S, Azzolina D, Gregori D, Malleo G, Golan T, Simeone DM, Davis MB, Vacca PG, Crovetto A, Bassi C, Salvia R, Biankin AV, Casolino R. A systematic review and meta-analysis of germline BRCA mutations in pancreatic cancer patients identifies global and racial disparities in access to genetic testing. ESMO Open 2023; 8:100881. [PMID: 36822114 PMCID: PMC10163165 DOI: 10.1016/j.esmoop.2023.100881] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 11/19/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Germline BRCA1 and BRCA2 mutations (gBRCAm) can inform pancreatic cancer (PC) risk and treatment but most of the available information is derived from white patients. The ethnic and geographic variability of gBRCAm prevalence and of germline BRCA (gBRCA) testing uptake in PC globally is largely unknown. MATERIALS AND METHODS We carried out a systematic review and prevalence meta-analysis of gBRCA testing and gBRCAm prevalence in PC patients stratified by ethnicity. The main outcome was the distribution of gBRCA testing uptake across diverse populations worldwide. Secondary outcomes included: geographic distribution of gBRCA testing uptake, temporal analysis of gBRCA testing uptake in ethnic groups, and pooled proportion of gBRCAm stratified by ethnicity. The study is listed under PROSPERO registration number #CRD42022311769. RESULTS A total of 51 studies with 16 621 patients were included. Twelve of the studies (23.5%) enrolled white patients only, 10 Asians only (19.6%), and 29 (56.9%) included mixed populations. The pooled prevalence of white, Asian, African American, and Hispanic patients tested per study was 88.7%, 34.8%, 3.6%, and 5.2%, respectively. The majority of included studies were from high-income countries (HICs) (64; 91.2%). Temporal analysis showed a significant increase only in white and Asians patients tested from 2000 to present (P < 0.001). The pooled prevalence of gBRCAm was: 3.3% in white, 1.7% in Asian, and negligible (<0.3%) in African American and Hispanic patients. CONCLUSIONS Data on gBRCA testing and gBRCAm in PC derive mostly from white patients and from HICs. This limits the interpretation of gBRCAm for treating PC across diverse populations and implies substantial global and racial disparities in access to BRCA testing in PC.
Collapse
Affiliation(s)
- S Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/Totuccio83
| | - D Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara
| | - D Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova, Italy. https://twitter.com/gregoriDario
| | - G Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/gimalleo
| | - T Golan
- Oncology Institute, Sheba Medical Center at Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - D M Simeone
- Department of Surgery, New York University, New York; Perlmutter Cancer Center, New York University, New York. https://twitter.com/MadameSurgeon
| | - M B Davis
- Department of Surgery and Surgical Oncology, Weill Cornell University, New York; Englander Institute of Precision Medicine, Weill Cornell University, New York, USA. https://twitter.com/MeliD32
| | - P G Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/pvhdfm
| | - A Crovetto
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/crovetto_a
| | - C Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona
| | - R Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona. https://twitter.com/SalviaRobi
| | - A V Biankin
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK; Faculty of Medicine, South Western Sydney Clinical School, University of NSW, Liverpool, Australia.
| | - R Casolino
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow.
| |
Collapse
|
6
|
Paiella S, Azzolina D, Trestini I, Malleo G, Nappo G, Ricci C, Ingaldi C, Vacca PG, De Pastena M, Secchettin E, Zamboni G, Maggino L, Corciulo MA, Sandini M, Cereda M, Capretti G, Casadei R, Bassi C, Mansueto G, Gregori D, Milella M, Zerbi A, Gianotti L, Salvia R. Body composition parameters, immunonutritional indexes, and surgical outcome of pancreatic cancer patients resected after neoadjuvant therapy: A retrospective, multicenter analysis. Front Nutr 2023; 10:1065294. [PMID: 36860690 PMCID: PMC9968808 DOI: 10.3389/fnut.2023.1065294] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/23/2023] [Indexed: 02/17/2023] Open
Abstract
Background and aims Body composition parameters and immunonutritional indexes provide useful information on the nutritional and inflammatory status of patients. We sought to investigate whether they predict the postoperative outcome in patients with pancreatic cancer (PC) who received neoadjuvant therapy (NAT) and then pancreaticoduodenectomy. Methods Data from locally advanced PC patients who underwent NAT followed by pancreaticoduodenectomy between January 2012 and December 2019 in four high-volume institutions were collected retrospectively. Only patients with two available CT scans (before and after NAT) and immunonutritional indexes (before surgery) available were included. Body composition was assessed and immunonutritional indexes collected were: VAT, SAT, SMI, SMA, PLR, NLR, LMR, and PNI. The postoperative outcomes evaluated were overall morbidity (any complication occurring), major complications (Clavien-Dindo ≥ 3), and length of stay. Results One hundred twenty-one patients met the inclusion criteria and constituted the study population. The median age at the diagnosis was 64 years (IQR16), and the median BMI was 24 kg/m2 (IQR 4.1). The median time between the two CT-scan examined was 188 days (IQR 48). Skeletal muscle index (SMI) decreased after NAT, with a median delta of -7.8 cm2/m2 (p < 0.05). Major complications occurred more frequently in patients with a lower pre-NAT SMI (p = 0.035) and in those who gained in subcutaneous adipose tissue (SAT) compartment during NAT (p = 0.043). Patients with a gain in SMI experienced fewer major postoperative complications (p = 0.002). The presence of Low muscle mass after NAT was associated with a longer hospital stay [Beta 5.1, 95%CI (1.5, 8.7), p = 0.006]. An increase in SMI from 35 to 40 cm2/m2 was a protective factor with respect to overall postoperative complications [OR 0.43, 95% (CI 0.21, 0.86), p < 0.001]. None of the immunonutritional indexes investigated predicted the postoperative outcome. Conclusion Body composition changes during NAT are associated with surgical outcome in PC patients who receive pancreaticoduodenectomy after NAT. An increase in SMI during NAT should be favored to ameliorate the postoperative outcome. Immunonutritional indexes did not show to be capable of predicting the surgical outcome.
Collapse
Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy,*Correspondence: Salvatore Paiella ✉
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Ilaria Trestini
- Dietetics Services, Hospital Medical Direction, University Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Claudio Ricci
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pier Giuseppe Vacca
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Giulia Zamboni
- Radiology Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Maggino
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Maria Assunta Corciulo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Marta Sandini
- General Surgery Unit, University of Siena, Siena, Italy
| | - Marco Cereda
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Riccardo Casadei
- Pancreatic Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, University of Bologna, Bologna, Italy,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy,IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and HPB Unit, San Gerardo Hospital Monza, Monza, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy,Roberto Salvia ✉
| |
Collapse
|
7
|
Bannone E, Marchegiani G, Perri G, Procida G, Vacca PG, Cattelani A, Salvia R, Bassi C. Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula. Surgery 2022; 172:715-722. [PMID: 35636983 DOI: 10.1016/j.surg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/16/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between postoperative serum hyperamylasaemia (POH) and morbidity has been hypothesized but rarely explored once occurring with or without (POH-exclusive) a combined postoperative pancreatic fistula (POPF). METHODS Analysis of patients who consecutively underwent pancreaticoduodenectomy from 2016 to 2020. POH was defined as serum amylase activity greater than the institutional upper limit of normal (52 U/L), persisting within the first 48 hours postoperatively (postoperative day [POD] 1 and 2). RESULTS Among 852 patients, 15.8% developed POH-exclusive. Compared with patients without POH or POPF (64.3%), they showed a significantly higher postoperative burden (Clavien-Dindo ≥II: 52.6% vs 30.8%) with increased rates of bacteraemia (12.6% vs 6%), pleural effusion (13.3% vs 5.3%), postpancreatectomy haemorrhage (13.3% vs 7.5%), postpancreatectomy acute pancreatitis (PPAP) (10.3% vs 0%), and organ site infections (18.5% vs 10.9%; all P < .05). A total of 13.8% experienced POH with POPF leading to the worse outcome. The combined occurrence of POH with POPF led to a shorter median time to morbidity (3 PODs, 95% confidence interval [CI] 2.2-3.7 vs 6 PODs, 95% CI 4.2-8; P < .001) than patients experiencing POPF-exclusive (5.9%). In all, 46.6% of POH patients developed POPF. Body mass index (BMI) (odds ratio [OR] 1.1), male sex (OR 2.1), increased drain fluid amylase on POD 1 (OR 1.001), and increased C-reactive protein (OR 1.01) were independent risk factors for POPF once POH has occurred. CONCLUSION POH has relevant postoperative clinical implications, independently from POPF occurrence. Developing POH with POPF leads to an earlier onset of higher postoperative burdens. Once POH is diagnosed, risk factors for additional POPF could identify patients who may benefit from additional surveillance, specific drains protocols, and preventive strategies.
Collapse
Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| |
Collapse
|