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Bashir A, Joseph N, Hammond JS, White S, Abu-El-Haija M, Drewes AM, Shaw JAM, Pandanaboyana S. Evaluating Continuous Glucose Monitoring After Total Pancreatectomy With or Without Islet Autotransplantation: A Scoping Systematic Review. Pancreas 2025; 54:e268-e277. [PMID: 39626176 DOI: 10.1097/mpa.0000000000002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2025]
Abstract
OBJECTIVES This scoping review aims to provide evidence synthesis of continuous glucose monitoring (CGM) and insulin pump use after undergone total pancreatectomy (TP) with or without islet autotransplantation (TPIAT). METHODS The review was conducted adhering to PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. RESULTS Fifteen studies including 147 patients (adult n = 71/pediatric n = 76) reported on CGM use post-TP (n = 42) and TPIAT (n = 105). Four were randomized controlled trials and 10 observational studies. Six studies evaluated CGM use in the perioperative and 6 in the immediate postoperative period (n = 8) with variable follow-up (14 hours to 20 months). CGM was used as a stand-alone device (8 studies), which allowed assessment of glycemic variability (n=5) and detection of hypoglycemia (n = 1), resulting in lower glucose levels (n = 1). Six studies evaluated insulin pump with CGM with reduction in postoperative mean glucose (n = 4) and hypoglycemic episodes (n = 2). No patient-reported outcome measures (PROMs) or quality of life (QoL) measures were reported. CONCLUSIONS CGM can be used following TP for glucose monitoring and/or linked with insulin pump device in the perioperative period with improved glycemic control. However, the data are limited by short follow-up and lack of PROMs and QoL measures.
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Affiliation(s)
| | - Nejo Joseph
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - John S Hammond
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Steve White
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Maisam Abu-El-Haija
- Department of Pediatrics, University of Cincinnati, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Asbjørn Mohr Drewes
- Center for Pancreatic Diseases, Department of Gastroenterology & Hepatology, & Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sanjay Pandanaboyana
- Department of Hepatobiliary Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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2
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Fancellu A, Maiore M, Grasso L, Ferrara M, Porcu A. Retroaortic left renal vein associated to variations of liver vasculature and biliary system in a patient submitted to total pancreatectomy. Hepatobiliary Pancreat Dis Int 2024; 23:526-529. [PMID: 37968191 DOI: 10.1016/j.hbpd.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 11/02/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Alessandro Fancellu
- Department of Medicine, Surgery and Pharmacy, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, Sassari 07100, Italy.
| | - Mario Maiore
- Department of Medicine, Surgery and Pharmacy, Unit of Radiology, University of Sassari, Sassari 07100, Italy
| | - Lavinia Grasso
- Department of Medicine, Surgery and Pharmacy, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, Sassari 07100, Italy
| | - Miriam Ferrara
- Department of Medicine, Surgery and Pharmacy, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, Sassari 07100, Italy
| | - Alberto Porcu
- Department of Medicine, Surgery and Pharmacy, Unit of General Surgery 2 - Clinica Chirurgica, University of Sassari, Sassari 07100, Italy
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3
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Paiella S, Secchettin E, Azzolina D, De Pastena M, Gentilini N, Trestini I, Casciani F, Sandini M, Lionetto G, Milella M, Malleo G, Gianotti L, Gregori D, Salvia R. Evaluation of five nutritional scores as predictors of postoperative outcome following pancreatic resection: A prospective, single-center study. Clin Nutr ESPEN 2024; 63:635-641. [PMID: 39053696 DOI: 10.1016/j.clnesp.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/07/2024] [Accepted: 07/15/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND AIMS Patients undergoing pancreatic resection are commonly malnourished. It is still unclear whether nutritional scores reliably predict postoperative outcomes after pancreatic resection. This study evaluated whether five commonly used preoperative nutritional screening scores predicted severe complications and length of stay. METHODS Patients scheduled for pancreatic resection (pancreatoduodenectomy, distal and total pancreatectomy) at a national referral center for pancreatic surgery from September 2022 to June 2023 were prospectively screened for malnutrition with MNA, MUST, SGA, SNAQ, and NRS2002 scores. Postoperative complications were classified using the Clavien-Dindo classification. #NCT05608538. RESULTS Three hundred patients were enrolled, including 168 pancreatoduodenectomies (56%), 102 distal pancreatectomies (34%), and 30 total pancreatectomies (10%). Final pathology revealed malignancy in 203 cases (67.7%). When applying the scores, the proportion of patients malnourished or at risk of malnutrition ranged from 21.7% for SGA to 79.3% for NRS2002. After adjusting for selected confounders, only an MNA <17 was associated with severe postoperative complications (OR 8.39, 95%CI [1.95-32.31], p = 0.01). MNA, SGA, and SNAQ predicted the length of stay (all p < 0.01), while MNA and SGA also correlated with a higher probability of having a greater heterogeneity in the length of stay (p = 0.04 and 0.002, respectively). DISCUSSION We promote using MNA to detect malnourished patients at risk of severe postoperative complications and longer hospitalization after pancreatic surgery. SGA and SNAQ may also have value in predicting patients who will be hospitalized longer. More prospective studies will be needed to corroborate these findings.
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Affiliation(s)
- Salvatore Paiella
- Pancreatic Surgery Unit, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona Hospital Trust, Verona, Italy; University of Verona, Verona, Italy.
| | - Erica Secchettin
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Matteo De Pastena
- Pancreatic Surgery Unit, Verona Integrated University Hospital, Policlinico GB Rossi, Verona, Italy
| | - Nicola Gentilini
- Pancreatic Surgery Unit, Verona Integrated University Hospital, Policlinico GB Rossi, Verona, Italy
| | - Ilaria Trestini
- Dietetic Service, Medical Direction, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Fabio Casciani
- Pancreatic Surgery Unit, Verona Integrated University Hospital, Policlinico GB Rossi, Verona, Italy
| | - Marta Sandini
- Department of Medical, Surgical, and Neurologic Sciences, University of Siena, Siena, Italy
| | - Gabriella Lionetto
- Pancreatic Surgery Unit, Verona Integrated University Hospital, Policlinico GB Rossi, Verona, Italy
| | - Michele Milella
- Section of Innovation Biomedicine-Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona, Verona, Italy
| | - Giuseppe Malleo
- Pancreatic Surgery Unit, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona Hospital Trust, Verona, Italy; University of Verona, Verona, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy; Hepatopancreaticobiliary Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Roberto Salvia
- University of Verona, Verona, Italy; Pancreatic Surgery Unit, Department of Engineering for Innovation Medicine (DIMI), University of Verona, Verona, Italy.
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4
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Ukegjini K, Müller PC, Warschkow R, Tarantino I, Petrowsky H, Gutschow CA, Schmied BM, Steffen T. Partial pancreatoduodenectomy versus total pancreatectomy in patients with preoperative diabetes mellitus: Comparison of surgical outcomes and quality of life. Langenbecks Arch Surg 2024; 409:254. [PMID: 39160361 DOI: 10.1007/s00423-024-03444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/04/2024] [Accepted: 08/10/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE To reduce perioperative risks among patients with a preoperative diabetes mellitus (DM) a total pancreatectomy (TP) might be a alternative to pancreatoduodenectomy (PD). This study aimed to compare the postoperative quality of life (QoL) of patients with preoperative DM undergoing PD or TP. METHODS A single-centre retrospective study was conducted, all consecutive patients with preoperative DM undergoing PD or TP between 2011 and 2023 were identified in a prospective database. The primary endpoint was QoL, prospectively assessed using EORTC QLQ-C30 questionnaires at 3, 6, and 12 months after surgery and then annually until death. Secondary endpoints were morbidity and mortality. RESULTS Seventy-one patients were included, 17 after TP and 54 after PD. Insulin-dependent DM occurred in 21 (39%) of the PD patients. QoL was worse after TP, especially in terms of physical functioning (-31.7 points; 95% CI: -50.0 to -13.3; P < 0.001), role functioning (-41.3 points; 95% CI: -61.3 to -21.3; P < 0.001), emotional functioning (-27.5 points; 95% CI: -50.4 to -4.6; P = 0.019), fatigue symptoms (20 points; 95% CI: 2.7 to 37.4; P = 0.024) and pain symptoms (30.2 points; 95% CI: 4.1 to 56.3; P = 0.024). The rates of postoperative major complications (29% vs. 35%; P = 0.853) and mortality (11% vs. 7%; P = 0.857) were similar between TP and PD. CONCLUSION Postoperative morbidity and mortality were comparable between PD and TP, however QoL is significantly lower after TP. Importantly, patients with preoperative DM have a 60% chance of remaining noninsulin-dependent after PD.
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Affiliation(s)
- Kristjan Ukegjini
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St, Gallen, Switzerland.
| | - Philip C Müller
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, Basel, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St, Gallen, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St, Gallen, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Christian A Gutschow
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St, Gallen, Switzerland
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St, Gallen, Switzerland
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Liu YH, Hu C, Yang XM, Zhang Y, Cao YL, Xiao F, Zhang JJ, Ma LQ, Zhou ZW, Hou SY, Wang E, Loepke AW, Deng M. Association of preoperative coronavirus disease 2019 with mortality, respiratory morbidity and extrapulmonary complications after elective, noncardiac surgery: An observational cohort study. J Clin Anesth 2024; 95:111467. [PMID: 38593491 DOI: 10.1016/j.jclinane.2024.111467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024]
Abstract
STUDY OBJECTIVE To assess the impact of preoperative infection with the contemporary strain of severe acute respiratory coronavirus 2 (SARS-CoV-2) on postoperative mortality, respiratory morbidity and extrapulmonary complications after elective, noncardiac surgery. DESIGN An ambidirectional observational cohort study. SETTING A tertiary and teaching hospital in Shanghai, China. PATIENTS All adult patients (≥ 18 years of age) who underwent elective, noncardiac surgery under general anesthesia at Huashan Hospital of Fudan University from January until March 2023 were screened for eligibility. A total of 2907 patients were included. EXPOSURE Preoperative coronavirus disease 2019 (COVID-19) positivity. MEASUREMENTS The primary outcome was 30-day postoperative mortality. The secondary outcomes included postoperative pulmonary complications (PPCs), myocardial injury after noncardiac surgery (MINS), acute kidney injury (AKI), postoperative delirium (POD) and postoperative sleep quality. Multivariable logistic regression was used to assess the risk of postoperative mortality and morbidity imposed by preoperative COVID-19. MAIN RESULTS The risk of 30-day postoperative mortality was not associated with preoperative COVID-19 [adjusted odds ratio (aOR), 95% confidence interval (CI): 0.40, 0.13-1.28, P = 0.123] or operation timing relative to diagnosis. Preoperative COVID-19 did not increase the risk of PPCs (aOR, 95% CI: 0.99, 0.71-1.38, P = 0.944), MINS (aOR, 95% CI: 0.54, 0.22-1.30; P = 0.168), or AKI (aOR, 95% CI: 0.34, 0.10-1.09; P = 0.070) or affect postoperative sleep quality. Patients who underwent surgery within 7 weeks after COVID-19 had increased odds of developing delirium (aOR, 95% CI: 2.26, 1.05-4.86, P = 0.036). CONCLUSIONS Preoperative COVID-19 or timing of surgery relative to diagnosis did not confer any added risk of 30-day postoperative mortality, PPCs, MINS or AKI. However, recent COVID-19 increased the risk of POD. Perioperative brain health should be considered during preoperative risk assessment for COVID-19 survivors.
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Affiliation(s)
- Yi-Heng Liu
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Chenghong Hu
- Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Xia-Min Yang
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Yu Zhang
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Yan-Ling Cao
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Fan Xiao
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Jun-Jie Zhang
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Li-Qing Ma
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Zi-Wen Zhou
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Si-Yu Hou
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - E Wang
- Department of Anesthesiology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Andreas W Loepke
- Department of Anesthesiology and Critical Care Medicine and Division of Cardiac Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China.
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Rompen IF, Habib JR, Sereni E, Stoop TF, Musa J, Cohen SM, Berman RS, Kaplan B, Hewitt DB, Sacks GD, Wolfgang CL, Javed AA. What is the optimal surgical approach for ductal adenocarcinoma of the pancreatic neck? - a retrospective cohort study. Langenbecks Arch Surg 2024; 409:224. [PMID: 39028426 DOI: 10.1007/s00423-024-03417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The appropriate surgical approach for pancreatic ductal adenocarcinoma (PDAC) is determined by the tumor's relation to the porto-mesenteric axis. Although the extent and location of lymphadenectomy is dependent on the type of resection, a pancreatoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) are considered equivalent oncologic operations for pancreatic neck tumors. Therefore, we aimed to assess differences in histopathological and oncological outcomes for surgical approaches in the treatment of pancreatic neck tumors. METHODS Patients with resected PDAC located in the pancreatic neck were identified from the National Cancer Database (2004-2020). Patients with metastatic disease were excluded. Furthermore, patients with 90-day mortality and R2-resections were excluded from the multivariable Cox-regression analysis. RESULTS Among 846 patients, 58% underwent PD, 25% DP, and 17% TP with similar R0-resection rates (p = 0.722). Significant differences were observed in nodal positivity (PD:44%, DP:34%, TP:57%, p < 0.001) and mean-number of examined lymph nodes (PD:17.2 ± 10.4, DP:14.7 ± 10.5, TP:21.2 ± 11.0, p < 0.001). Furthermore, inadequate lymphadenectomy (< 12 nodes) was observed in 30%, 44%, and 19% of patients undergoing PD, DP, and TP, respectively (p < 0.001). Multivariable analysis yielded similar overall survival after DP (HR:0.83, 95%CI:0.63-1.11), while TP was associated with worse survival (HR:1.43, 95%CI:1.08-1.89) compared to PD. CONCLUSION While R0-rates are similar amongst all approaches, DP is associated with inadequate lymphadenectomy which may result in understaging disease. However, this had no negative influence on survival. In the premise that an oncological resection of the pancreatic neck tumor is feasible with a partial pancreatectomy, no benefit is observed by performing a TP.
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Affiliation(s)
- Ingmar F Rompen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Joseph R Habib
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisabetta Sereni
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Thomas F Stoop
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Julian Musa
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Steven M Cohen
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Russell S Berman
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Brian Kaplan
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - D Brock Hewitt
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Greg D Sacks
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Christopher L Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Ammar A Javed
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA.
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Verdeyen N, Gryspeerdt F, Abreu de Carvalho L, Dries P, Berrevoet F. A Comparison of Preoperative Predictive Scoring Systems for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy Based on a Single-Center Analysis. J Clin Med 2024; 13:3286. [PMID: 38892998 PMCID: PMC11172640 DOI: 10.3390/jcm13113286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 05/26/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is associated with major postoperative morbidity and mortality. Several scoring systems have been described to stratify patients into risk groups according to the risk of POPF. The aim of this study was to compare scoring systems in patients who underwent a PD. Methods: A total of 196 patients undergoing PD from July 2019 to June 2022 were identified from a prospectively maintained database of the University Hospital Ghent. After performing a literature search, four validated, solely preoperative risk scores and the intraoperative Fistula Risk Score (FRS) were included in our analysis. Furthermore, we eliminated the variable blood loss (BL) from the FRS and created an additional score. Univariate and multivariate analyses were performed for all risk factors, followed by a ROC analysis for the six scoring systems. Results: All scores showed strong prognostic stratification for developing POPF (p < 0.001). FRS showed the best predictive accuracy in general (AUC 0.862). FRS without BL presented the best prognostic value of the scores that included solely preoperative variables (AUC 0.783). Soft pancreatic texture, male gender, and diameter of the Wirsung duct were independent prognostic factors on multivariate analysis. Conclusions: Although all predictive scoring systems stratify patients accurately by risk of POPF, preoperative risk stratification could improve clinical decision-making and implement preventive strategies for high-risk patients. Therefore, the preoperative use of the FRS without BL is a potential alternative.
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Affiliation(s)
- Naomi Verdeyen
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium;
| | - Filip Gryspeerdt
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Luìs Abreu de Carvalho
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Pieter Dries
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, 9000 Ghent, Belgium; (F.G.); (L.A.d.C.); (P.D.)
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8
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Ailhaud A, Girard E, Fournier J, Abba J, Devant E, Betry C, Risse O, Roth GS, d'Engremont C, Chirica M. Completion pancreatectomy during pancreatoduodenectomy: A lifesaving solution in high-risk patients. World J Surg 2024; 48:1123-1131. [PMID: 38553833 DOI: 10.1002/wjs.12159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice. METHODS Between 2014 and 2023, 139 patients (76 men, median age 67 years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75 years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison. RESULTS Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14 days [11; 18] vs. 17 days [13; 24], p = 0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p < 0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates. CONCLUSION The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.
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Affiliation(s)
- Antoine Ailhaud
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC, Grenoble, France
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Edouard Girard
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC, Grenoble, France
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Joey Fournier
- Department of Public Health Centre, Hospitalier Grenoble Alpes, Grenoble, France
| | - Julio Abba
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Emmanuel Devant
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Cecile Betry
- Univ. Grenoble Alpes, LRB, INSERM, Endocrinology Department, CHU Grenoble Alpes, Grenoble, France
| | - Olivier Risse
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Gaël S Roth
- Univ. Grenoble Alpes/Hepato-Gastroenterology and Digestive Oncology Department, CHU Grenoble Alpes/Institute for Advanced Biosciences, CNRS UMR 5309-INSERM U1209, Grenoble, France
| | - Christelle d'Engremont
- Univ. Grenoble Alpes/Hepato-Gastroenterology and Digestive Oncology Department, CHU Grenoble Alpes/Institute for Advanced Biosciences, CNRS UMR 5309-INSERM U1209, Grenoble, France
| | - Mircea Chirica
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC, Grenoble, France
- Department of Digestive Surgery, University Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
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9
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Li SZ, Zhen TT, Wu Y, Wang M, Qin TT, Zhang H, Qin RY. Quality of life after pancreatic surgery. World J Gastroenterol 2024; 30:943-955. [PMID: 38516249 PMCID: PMC10950648 DOI: 10.3748/wjg.v30.i8.943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/29/2023] [Accepted: 01/31/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas. Increasing attention has been paid to changes in quality of life (QOL) after pancreatic surgery. AIM To summarize and analyze current research results on QOL after pancreatic surgery. METHODS A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were identified by screening the references of retrieved articles. Studies on patients' QOL after pancreatic surgery published after January 1, 2012, were included. These included prospective and retrospective studies on patients' QOL after several types of pancreatic surgeries. The results of these primary studies were summarized inductively. RESULTS A total of 45 articles were included in the study, of which 13 were related to pancreaticoduodenectomy (PD), seven to duodenum-preserving pancreatic head resection (DPPHR), nine to distal pancreatectomy (DP), two to central pancreatectomy (CP), and 14 to total pancreatectomy (TP). Some studies showed that 3-6 months were needed for QOL recovery after PD, whereas others showed that 6-12 months was more accurate. Although TP and PD had similar influences on QOL, patients needed longer to recover to preoperative or baseline levels after TP. The QOL was better after DPPHR than PD. However, the superiority of the QOL between patients who underwent CP and PD remains controversial. The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL. Minimally invasive surgery could improve patients' QOL in the early stages after PD and DP; however, the long-term effect remains unclear. CONCLUSION The procedure among PD, DP, CP, and TP with a superior postoperative QOL is controversial. The long-term benefits of minimally invasive versus open surgeries remain unclear. Further prospective trials are warranted.
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Affiliation(s)
- Shi-Zhen Li
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ting-Ting Zhen
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ting-Ting Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hang Zhang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ren-Yi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Theijse RT, Stoop TF, Hendriks TE, Suurmeijer JA, Smits FJ, Bonsing BA, Lips DJ, Manusama E, van der Harst E, Patijn GA, Wijsman JH, Meerdink M, den Dulk M, van Dam R, Stommel MW, van Laarhoven K, de Wilde RF, Festen S, Draaisma WA, Bosscha K, van Eijck CH, Busch OR, Molenaar IQ, Groot Koerkamp B, van Santvoort HC, Besselink MG. Nationwide Outcome after Pancreatoduodenectomy in Patients at very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula. Ann Surg 2023; 281:00000658-990000000-00717. [PMID: 38073575 PMCID: PMC11723487 DOI: 10.1097/sla.0000000000006174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D. SUMMARY BACKGROUND DATA Morbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking. METHODS Nationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed. RESULTS Overall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%). CONCLUSION This nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.
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Affiliation(s)
- Rutger T. Theijse
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Thomas F. Stoop
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Division of Surgical Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Tessa E. Hendriks
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J. Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Eric Manusama
- Department of Surgery, Medisch Centrum Leeuwarden, the Netherlands
| | | | - Gijs A. Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Jan H. Wijsman
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Mark Meerdink
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
- NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
| | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kees van Laarhoven
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | | | - Werner A. Draaisma
- Department of Surgery, Jeroen Bosch Hospital, ‘s Hertogenbosch, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, ‘s Hertogenbosch, the Netherlands
| | - Casper H.J. van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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11
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Stoop TF, Bergquist E, Theijse RT, Hempel S, van Dieren S, Sparrelid E, Distler M, Hackert T, Besselink MG, Del Chiaro M, Ghorbani P. Systematic Review and Meta-analysis of the Role of Total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula: Is it a Justifiable Indication? Ann Surg 2023; 278:e702-e711. [PMID: 37161977 PMCID: PMC10481933 DOI: 10.1097/sla.0000000000005895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking. METHODS Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life. RESULTS After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P =0.857). CONCLUSIONS This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.
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Affiliation(s)
- Thomas F. Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Erik Bergquist
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Rutger T. Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
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12
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Jeo WS, Razi K, Setiawan A, Natasya, Welly Hartono R. Total pancreatoduodenectomy for multiple pancreatic cysts in von Hippel-Lindau disease presenting as obstructive jaundice: A case report. Int J Surg Case Rep 2023; 109:108481. [PMID: 37454549 PMCID: PMC10384223 DOI: 10.1016/j.ijscr.2023.108481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Von Hippel-Lindau (VHL) disease can be known as a rare autosomal dominant syndrome that affects some organ systems and is characterized by the growth of both benign and malignant tumors. Diagnosis and management of VHL were needed to have better outcomes. CASE PRESENTATION A 39-year-old male with a history of VHL disease and positive family history presented with jaundice and pruritus. He had a history of craniotomy thrice. Laboratory workup revealed elevated total bilirubin level with conjugated bilirubin predominant. The contrast-enhanced MRI showed dilatation of biliary tree with suspicion of partial obstruction by multiple cysts in the pancreas, with ±0.5-5 cm in diameter. A PET/CT scan showed multiple lesions corresponding to VHL disease. The patient underwent total pancreatoduodenectomy. The histopathology finding was multicystic pancreatic hamartoma with neuroendocrine cell hyperplasia. CLINICAL DISCUSSION Multiple pancreatic cysts without prior pancreatic inflammatory episodes should suggest VHL disease and prompt a genetic test, according to clinical presentation. As soon as the diagnosis is made, all potential family members must be screened, and those who are affected must receive genetic counseling and strict follow-up care to treat the disease's potentially fatal CNS and visceral manifestations. Total pancreatoduodenectomy was performed according to jaundice, risk of pancreas malignancy, and the existence of endocrine pancreatic insufficiency. CONCLUSION Total pancreatoduodenectomy could be performed to relieve the symptom severity and avoid the possibility of malignant changes in VHL.
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Affiliation(s)
- Wifanto Saditya Jeo
- Division of Digestive Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia; Department of Digestive Surgery, Siloam Hospital Kebon Jeruk, Jakarta, Indonesia.
| | - Khalikul Razi
- Division of Digestive Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Andre Setiawan
- Department of Digestive Surgery, Siloam Hospital Kebon Jeruk, Jakarta, Indonesia
| | - Natasya
- Division of Digestive Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - R Welly Hartono
- Department of Pathology Anatomy, Siloam Hospital Kebon Jeruk, Jakarta, Indonesia
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13
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Kanemitsu E, Masui T, Hatano E. ASO Author Reflections: Evaluating the Safety of Completion Total Pancreatectomy Compared with Initial Total Pancreatectomy. Ann Surg Oncol 2023; 30:4407-4408. [PMID: 36933083 DOI: 10.1245/s10434-023-13358-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Affiliation(s)
- Eisho Kanemitsu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshihiko Masui
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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14
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Kanemitsu E, Masui T, Nagai K, Anazawa T, Kasai Y, Yogo A, Ito T, Mori A, Takaori K, Uemoto S, Hatano E. Propensity Score Matching Analysis of the Safety of Completion Total Pancreatectomy for Remnant Pancreatic Tumors Versus that of Initial Total Pancreatectomy for Primary Pancreatic Tumors. Ann Surg Oncol 2023; 30:4392-4406. [PMID: 36933081 DOI: 10.1245/s10434-023-13309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/15/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The safety and feasibility of completion total pancreatectomy (TP) for remnant pancreatic neoplasms remain controversial and are rarely compared with that of initial TP. Thus, we aimed to compare the safety of these two procedures inducing a pancreatic state. METHODS Patients who underwent TP for pancreatic neoplasms between 2006 and 2018 at our institution were included in this study. Tumor pathologies were classified into three subgroups according to survival curves. We used 1:1 propensity score matching (PSM) to analyze age, sex, Charlson Comorbidity Index, and tumor stage. Finally, we analyzed the primary outcome Clavien-Dindo classification (CDC) grade, risks of other safety-related outcomes, and the survival rate of patients with invasive cancer. RESULTS Of 54 patients, 16 underwent completion TP (29.6%) and 38 (70.4%) underwent initial TP. Before PSM analysis, age and Charlson Comorbidity Index were significantly higher, and T category and stage were significantly lower for the completion TP group. Upon PSM analysis, these two groups were equivalent in CDC grade [initial TP vs. completion TP: 71.4% (10/14) vs. 78.6% (11/14); p = 0.678] and other safety-related outcomes. Additionally, while the overall survival and recurrence-free survival of patients with invasive cancer were not significantly different between these two groups, the T category and stage tended to be remarkably severe in the initial TP group. CONCLUSIONS PSM analysis for prognostic factors showed that completion TP and initial TP have similar safety-related outcomes that can be used as a decision-making reference in the surgery of pancreatic tumors.
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Affiliation(s)
- Eisho Kanemitsu
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshihiko Masui
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Kazuyuki Nagai
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Kasai
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akitada Yogo
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuo Ito
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akira Mori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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15
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Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
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Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
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16
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Triantopoulou C, Gourtsoyianni S, Karakaxas D, Delis S. Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Challenging Diagnosis. Diagnostics (Basel) 2023; 13:2015. [PMID: 37370909 DOI: 10.3390/diagnostics13122015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) was classified as a distinct entity from mucinous cystic neoplasm by the WHO in 1995. It represents a mucin-producing tumor that originates from the ductal epithelium and can evolve from slight dysplasia to invasive carcinoma. In addition, different aspects of tumor progression may be seen in the same lesion. Three types are recognized, the branch duct variant, the main duct variant, which shows a much higher prevalence for malignancy, and the mixed-type variant, which combines branch and main duct characteristics. Advances in cross-sectional imaging have led to an increased rate of IPMN detection. The main imaging characteristic of IPMN is the dilatation of the pancreatic duct without the presence of an obstructing lesion. The diagnosis of a branch duct IPMN is based on the proof of its communication with the main pancreatic duct on MRI-MRCP examination. Early identification by imaging of the so-called worrisome features or predictors for malignancy is an important and challenging task. In this review, we will present recent imaging advances in the diagnosis and characterization of different types of IPMNs, as well as imaging tools available for early recognition of worrisome features for malignancy. A critical appraisal of current IPMN management guidelines from both a radiologist's and surgeon's perspective will be made. Special mention is made of complications that might arise during the course of IPMNs as well as concomitant pancreatic neoplasms including pancreatic adenocarcinoma and pancreatic endocrine neoplasms. Finally, recent research on prognostic and predictive biomarkers including radiomics will be discussed.
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Affiliation(s)
| | - Sofia Gourtsoyianni
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, 11528 Athens, Greece
| | - Dimitriοs Karakaxas
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
| | - Spiros Delis
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
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17
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Balzano G, Zerbi A, Aleotti F, Capretti G, Melzi R, Pecorelli N, Mercalli A, Nano R, Magistretti P, Gavazzi F, De Cobelli F, Poretti D, Scavini M, Molinari C, Partelli S, Crippa S, Maffi P, Falconi M, Piemonti L. Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Ann Surg 2023; 277:894-903. [PMID: 36177837 PMCID: PMC10174105 DOI: 10.1097/sla.0000000000005713] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with islet autotransplantation (IAT) in patients at high risk of postoperative pancreatic fistula (POPF). BACKGROUND Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences. METHODS Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (ie, soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery. RESULTS Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TP-IAT ( P =0.008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [odds ratio (OR)=7.64 (95% CI: 1.35-43.3), P =0.022], while the OR for grade ≥3 complications was 2.82 (95% CI: 0.86-9.24, P =0.086). After TP-IAT, the postoperative stay was shorter [median: 10.5 vs 16.0 days; P <0.001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival, and overall survival. TP-IAT was associated with a higher risk of diabetes [hazard ratio=9.1 (95% CI: 3.76-21.9), P <0.0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time. CONCLUSIONS TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.
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Affiliation(s)
- Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Francesca Aleotti
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Molinari
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Maffi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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18
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Pausch TM, Liu X, Dincher J, Contin P, Cui J, Wei J, Heger U, Lang M, Tanaka M, Heap S, Kaiser J, Klotz R, Probst P, Miao Y, Hackert T. Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003-2021. J Clin Med 2023; 12:jcm12052013. [PMID: 36902800 PMCID: PMC10003839 DOI: 10.3390/jcm12052013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Middle segment-preserving pancreatectomy (MPP) can treat multilocular diseases in the pancreatic head and tail while avoiding impairments caused by total pancreatectomy (TP). We conducted a systematic literature review of MPP cases and collected individual patient data (IPD). MPP patients (N = 29) were analyzed and compared to a group of TP patients (N = 14) in terms of clinical baseline characteristics, intraoperative course, and postoperative outcomes. We also conducted a limited survival analysis following MPP. Pancreatic functionality was better preserved following MPP than TP, as new-onset diabetes and exocrine insufficiency each occurred in 29% of MPP patients compared to near-ubiquitous prevalence among TP patients. Nevertheless, POPF Grade B occurred in 54% of MPP patients, a complication avoidable with TP. Longer pancreatic remnants were a prognostic indicator for shorter and less eventful hospital stays with fewer complications, whereas complications of endocrine functionality were associated with older patients. Long-term survival prospects after MPP appeared strong (median up to 110 months), but survival was lower in cases with recurring malignancies and metastases (median < 40 months). This study demonstrates MPP is a feasible treatment alternative to TP for selected cases because it can avoid pancreoprivic impairments, but at the risk of perioperative morbidity.
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Affiliation(s)
- Thomas M. Pausch
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-565150
| | - Xinchun Liu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Department of Gastrointestinal Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Josefine Dincher
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Pietro Contin
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jiaqu Cui
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Matthias Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Stephen Heap
- Study Center of the German Society of Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Jörg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Study Center of the German Society of Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Surgery, Cantonal Hospital Thurgau, 8501 Frauenfeld, Switzerland
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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19
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Balzano G, Zerbi A, Scavini M, Piemonti L. Response to: Comment on: Pancreatectomy With Islet-Autotransplantation as Alternative for Pancreato-Duodenectomy in Patients With a High-Risk for Postoperative Pancreatic Fistula: The Jury Is Still Out. ANNALS OF SURGERY OPEN 2023; 4:e261. [PMID: 37600887 PMCID: PMC10431506 DOI: 10.1097/as9.0000000000000261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/31/2023] Open
Affiliation(s)
- Gianpaolo Balzano
- From the Unit of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- General Surgery, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery Operating Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Clinical Care Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Lorenzo Piemonti
- Vita-Salute San Raffaele University, Diabetes Research Institute, Regenerative Medicine and Transplant Unit, IRCCS Ospedale San Raffaele, Milan, Italy
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20
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Masuda H, Kotecha K, Maitra R, Maher R, Mittal A, Samra JS. The role of repeated imaging in detecting complications in the post-operative period following pancreaticoduodenectomy: Serial CT imaging post-pancreaticoduodenectomy. ANZ J Surg 2023; 93:1314-1321. [PMID: 36782399 DOI: 10.1111/ans.18327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Post-pancreaticoduodenectomy haemorrhage is a potentially life-threatening complication. Delay in the detection and subsequent management of complications contribute significantly to post-operative mortality and morbidity associated with pancreaticoduodenectomy. METHODS All patients undergoing pancreaticoduodenectomy at an Australian-based tertiary referral center between 2017 and 2022 were reviewed retrospectively. We identified those patients who suffered a post-pancreaticoduodenectomy haemorrhage and further analysed those patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeated CT imaging performed within 24 h of their previous CT scan. RESULTS A total of 232 pancreaticoduodenectomies were identified for analysis during the study period, of which 23 patients (9.9%) suffered a post-pancreaticoduodenectomy haemorrhage. We present four patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeat CT scan in the setting of a recent (within 24 h) CT scan which showed no evidence of active haemorrhage or pseudoaneurysm formation. All patients received prompt and definitive endovascular management through stent insertion or coil embolization resulting in successful cessation of bleeding. Three patients made an uncomplicated recovery thereafter. Unfortunately, one patient died as a complication of the bleed despite early and definitive endovascular intervention. CONCLUSION Our study highlights the importance of having a low threshold for repeated CT imaging in the post-pancreaticoduodenectomy setting, particularly when there remains a high index of suspicion clinically for a post-operative complication, even in the context of previous benign imaging. Given the complexity of pancreaticoduodenectomy, we believe early detection with liberal imaging allows the best chance at successfully managing the morbidity and mortality associated in the post-pancreaticoduodenectomy setting.
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Affiliation(s)
- Hiro Masuda
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Rudra Maitra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Richard Maher
- Department of Interventional Radiology, Royal North Shore Hospital and North Shore Private Hospital, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
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21
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Masuda Y, Kiritani S, Arita J, Ichida A, Kawaguchi Y, Akamatsu N, Kaneko J, Hasegawa K. Transient loss of consciousness immediately after total pancreatectomy for pancreatic metastases from renal cell carcinoma: a case report. Surg Case Rep 2023; 9:3. [PMID: 36622508 PMCID: PMC9829935 DOI: 10.1186/s40792-022-01583-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/27/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Total pancreatectomy (TP) is often selected for treatment of various pancreatic diseases. However, the resultant lack of autoregulation of glycometabolism necessitates careful postoperative management. CASE PRESENTATION A 77-year-old man who had undergone right nephrectomy for renal cell carcinoma 11 years previously presented with multiple histologically diagnosed pancreatic metastases. The patient had no notable comorbidities, including diabetes. Because no extrapancreatic organ metastasis was identified, he underwent TP as a curative treatment. He awoke from anesthesia and was extubated without any problems in the operating room. However, 15 min after entering the intensive care unit, he suddenly lost consciousness and became apneic, resulting in reintubation. Blood gas analysis revealed an increased glucose concentration (302 mg/dL) and mixed acid-base disorder (pH of 7.21) due to insulin insufficiency and fentanyl administration. After induction of continuous intravenous insulin infusion and termination of fentanyl, the glucose concentration and pH gradually improved. He regained clear consciousness and spontaneous ventilation and was extubated the next day with no difficulties or complications. CONCLUSION This case highlights the importance of active monitoring of the glycemic state and pH after TP because of the possibility of deterioration due to TP itself as well as the lingering effects of anesthesia.
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Affiliation(s)
- Yasutaka Masuda
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Sho Kiritani
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Junichi Arita
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Akihiko Ichida
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Yoshikuni Kawaguchi
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Nobuhisa Akamatsu
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Junichi Kaneko
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
| | - Kiyoshi Hasegawa
- grid.26999.3d0000 0001 2151 536XHepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655 Japan
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22
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Zhao T, Fu Y, Zhang T, Guo J, Liao Q, Song S, Duo Y, Gao Y, Yuan T, Zhao W. Diabetes management in patients undergoing total pancreatectomy: A single center cohort study. Front Endocrinol (Lausanne) 2023; 14:1097139. [PMID: 36860372 PMCID: PMC9969079 DOI: 10.3389/fendo.2023.1097139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Total pancreatectomy (TP) has been increasingly performed in recent years. However, studies on diabetes management after TP during different postoperative periods are still limited. OBJECTIVES This study aimed to evaluate the glycemic control and insulin therapy of patients undergoing TP during the perioperative and long-term follow-up period. METHODS Ninety-three patients undergoing TP for diffuse pancreatic tumors from a single center in China were included. Based on preoperative glycemic status, patients were divided into three groups: nondiabetic group (NDG, n = 41), short-duration diabetic group (SDG, preoperative diabetes duration ≤12 months, n = 22), and long-duration diabetic group (LDG, preoperative diabetes duration >12 months, n = 30). Perioperative and long-term follow-up data, including the survival rate, glycemic control, and insulin regimens, were evaluated. Comparative analysis with complete insulin-deficient type 1 diabetes mellitus (T1DM) was conducted. RESULTS During hospitalization after TP, glucose values within the target (4.4-10.0 mmol/L) accounted for 43.3% of the total data, and 45.2% of the patients experienced hypoglycemic events. Patients received continuous intravenous insulin infusion during parenteral nutrition at a daily insulin dose of 1.20 ± 0.47 units/kg/day. In the long-term follow-up period, glycosylated hemoglobin A1c levels of 7.43 ± 0.76% in patients following TP, as well as time in range and coefficient of variation assessed by continuous glucose monitoring, were similar to those in patients with T1DM. However, patients after TP had lower daily insulin dose (0.49 ± 0.19 vs 0.65 ± 0.19 units/kg/day, P < 0.001) and basal insulin percentage (39.4 ± 16.5 vs 43.9 ± 9.9%, P = 0.035) than patients with T1DM, so did those using insulin pump therapy. Whether in the perioperative or long-term follow-up period, daily insulin dose was significantly higher in LDG patients than in NDG and SDG patients. CONCLUSIONS Insulin dose in patients undergoing TP varied according to different postoperative periods. During long-term follow-up, glycemic control and variability following TP were comparable to complete insulin-deficient T1DM but with fewer insulin needs. Preoperative glycemic status should be evaluated as it could guide insulin therapy after TP.
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Affiliation(s)
- Tianyi Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Fu
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junchao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuoning Song
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yanbei Duo
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuting Gao
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Tao Yuan
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Tao Yuan, ; Weigang Zhao,
| | - Weigang Zhao
- Department of Endocrinology, Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Tao Yuan, ; Weigang Zhao,
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23
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Zhu J, Jiang Z, Xie B, Fu C, Xiao W, Li Y. Comparison of oncologic outcomes between pancreaticoduodenectomy and total pancreatectomy for pancreatic adenocarcinoma. Surg Endosc 2023; 37:109-119. [PMID: 35851818 DOI: 10.1007/s00464-022-09441-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 07/04/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) and total pancreatectomy (TP) are two surgical methods to treat patients with pancreatic head adenocarcinoma (PHAC). However, the oncologic outcomes of TP for PHAC remain controversial. In this study, we compared early mortality and long-term survival patients undergoing TP and those with PD. METHODS All patients diagnosed with non-metastatic PHAC who underwent PD or TP from 1988 to 2016 were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to balance the inter-group covariates. Cancer-specific survival (CSS) was the primary endpoint. RESULTS A total of 4748 patients (743 TP and 4005 PD) were included in the study. Some 740 patients who underwent TP were matched with 1479 who had PD. After PSM, there was no difference between TP and PD groups regarding 30-day mortality (3.5% vs. 2.7%, p = 0.290) and 90-day mortality (9.9% vs. 8%, p = 0.135). More importantly, TP showed comparable survival in comparison to PD, prior or after excluding patients who died within 30 and 90 days. Besides, multivariate analysis revealed that tumor size, tumor stage, N stage, chemotherapy, and radiation were significant prognostic factors. CONCLUSION PD and TP have similar early mortality and long-term survival for patients with PHAC. In selected patients, TP can be used when oncologically appropriate.
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Affiliation(s)
- Jisheng Zhu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Zhengying Jiang
- Department of Bun, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Bin Xie
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Chengchao Fu
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Weidong Xiao
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China
| | - Yong Li
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China.
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24
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Marchegiani G, Perri G, Burelli A, Zoccatelli F, Andrianello S, Luchini C, Donadello K, Bassi C, Salvia R. High-risk Pancreatic Anastomosis Versus Total Pancreatectomy After Pancreatoduodenectomy: Postoperative Outcomes and Quality of Life Analysis. Ann Surg 2022; 276:e905-e913. [PMID: 33914471 DOI: 10.1097/sla.0000000000004840] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate TP as an alternative to PD in patients at high-risk for popf. BACKGROUND Outcomes of high-risk PD (HR-PD) and TP have never been compared. METHODS All patients who underwent PD or TP between July 2017 and December 2019 were identified. HR-PD was defined according to the alternative fistula risk score. Postoperative outcomes (primary endpoint), pancreatic insufficiency, and quality of life after 12 months of follow-up (QoL) were compared between HR-PD or planned PD intraoperatively converted to TP (C-TP). RESULTS A total of 566 patients underwent PD and 136 underwent TP during the study period. One hundred one (18%) PD patients underwent HR-PD, whereas 86 (63%) TP patients underwent C-TP. Postoperatively, the patients in the C-TP group exhibited lower rates of postpancreatectomy hemorrhage (15% vs 28%), delayed gastric emptying (16% vs 34%), sepsis (10% vs 31%), and Clavien-Dindo ≥3 morbidity (19% vs 31%) and had shorter median lengths of hospital stay (10 vs 21 days) (all P < 0.05). The rate of POPF in the HR-PD group was 39%. Mortality was comparable between the 2 groups (3% vs 4%). Although general, cancer- and pancreas-specific QoL were comparable between the HR-PD and C-TP groups, endocrine and exocrine insufficiency occurred in all the C-TP patients, compared to only 13% and 63% of the HR-PD patients, respectively, and C-TP patients had worse diabetesspecific QoL. CONCLUSIONS C-TP may be considered rather than HR-PD only in few selected cases and after adequate counseling.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Anna Burelli
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Fabio Zoccatelli
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Luchini
- Department of Pathology, Verona University Hospital, Verona, Italy
| | - Katia Donadello
- Department of Anesthesia and Intensive Care, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
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25
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Latenstein AEJ, Scholten L, Al-Saffar HA, Björnsson B, Butturini G, Capretti G, Chatzizacharias NA, Dervenis C, Frigerio I, Gallagher TK, Gasteiger S, Halimi A, Labori KJ, Montagnini G, Muñoz-Bellvis L, Nappo G, Nikov A, Pando E, Pastena MD, Peña-Moral JMDL, Radenkovic D, Roberts KJ, Salvia R, Sanchez-Bueno F, Scandavini C, Serradilla-Martin M, Stättner S, Tomazic A, Varga M, Zavrtanik H, Zerbi A, Erkan M, Kleeff J, Lesurtel M, Besselink MG, Ramia-Angel JM. Clinical Outcomes After Total Pancreatectomy: A Prospective Multicenter Pan-European Snapshot Study. Ann Surg 2022; 276:e536-e543. [PMID: 33177356 DOI: 10.1097/sla.0000000000004551] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess outcomes among patients undergoing total pancreatectomy (TP) including predictors for complications and in-hospital mortality. BACKGROUND Current studies on TP mostly originate from high-volume centers and span long time periods and therefore may not reflect daily practice. METHODS This prospective pan-European snapshot study included patients who underwent elective (primary or completion) TP in 43 centers in 16 European countries (June 2018-June 2019). Subgroup analysis included cutoff values for annual volume of pancreatoduodenectomies (<60 vs ≥60).Predictors for major complications and in-hospital mortality were assessed in multivariable logistic regression. RESULTS In total, 277 patients underwent TP, mostly for malignant disease (73%). Major postoperative complications occurred in 70 patients (25%). Median hospital stay was 12 days (IQR 9-18) and 40 patients were readmitted (15%). In-hospital mortality was 5% and 90-day mortality 8%. In the subgroup analysis, in-hospital mortality was lower in patients operated in centers with ≥60 pancreatoduodenectomies compared <60 (4% vs 10%, P = 0.046). In multivariable analysis, annual volume <60 pancreatoduodenectomies (OR 3.78, 95% CI 1.18-12.16, P = 0.026), age (OR 1.07, 95% CI 1.01-1.14, P = 0.046), and estimated blood loss ≥2L (OR 11.89, 95% CI 2.64-53.61, P = 0.001) were associated with in-hospital mortality. ASA ≥3 (OR 2.87, 95% CI 1.56-5.26, P = 0.001) and estimated blood loss ≥2L (OR 3.52, 95% CI 1.25-9.90, P = 0.017) were associated with major complications. CONCLUSION This pan-European prospective snapshot study found a 5% inhospital mortality after TP. The identified predictors for mortality, including low-volume centers, age, and increased blood loss, may be used to improve outcomes.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hasan Ahmad Al-Saffar
- HPB-Unit, Department of Upper GI diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bergthor Björnsson
- Department of Surgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Giovanni Butturini
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS and Humanitas University Department of Biomedical Sciences, Rozzano, Pieve Emanuele, Milan, Italy
| | - Nikolaos A Chatzizacharias
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Chris Dervenis
- Department of General Surgery, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Isabella Frigerio
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Tom K Gallagher
- Department of HPB and Transplant Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Silvia Gasteiger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Asif Halimi
- HPB-Unit, Department of Upper GI diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Greta Montagnini
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luis Muñoz-Bellvis
- Department of Surgery, University of Salamanca/HospitalUniversitario de Salamanca, Salamanca, Spain
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS and Humanitas University Department of Biomedical Sciences, Rozzano, Pieve Emanuele, Milan, Italy
| | - Andrej Nikov
- Department of Surgery, Central Military Hospital Prague, Prague, Czech Republic
| | - Elizabeth Pando
- Department of Hepatopancreatobiliary and Transplant surgery, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Matteo de Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Jesús M de la Peña-Moral
- Department of Pathology, Hospital Clínico Universitario ''Virgen de la Arrixaca,'' Murcia, Spain
| | - Dejan Radenkovic
- Department of Digestive Surgery, Clinical center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Keith J Roberts
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Francisco Sanchez-Bueno
- Department of Surgery, Hospital Cli´nico Universitario ''Virgen de la Arrixaca,''Murcia, Spain
| | - Chiara Scandavini
- HPB-Unit, Department of Upper GI diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Department of Surgery, Salzkammergut Klinikum, Vöcklabruck, Austria
| | - Ales Tomazic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Martin Varga
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Hana Zavrtanik
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS and Humanitas University Department of Biomedical Sciences, Rozzano, Pieve Emanuele, Milan, Italy
| | - Mert Erkan
- Department of Surgery, Koc University, Istanbul, Turkey
| | - Jörg Kleeff
- Department of Visceral, Vascular, and Endocrine Surgery, Martin Luther University, Halle-Wittenberg, Germany
| | - Mickaël Lesurtel
- Department of Digestive Surgery & Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jose M Ramia-Angel
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara, Spain
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Jung JH, Yoon SJ, Lee OJ, Shin SH, Heo JS, Han IW. Is it worthy to perform total pancreatectomy considering morbidity and mortality?: Experience from a high-volume single center. Medicine (Baltimore) 2022; 101:e30390. [PMID: 36086699 PMCID: PMC10980437 DOI: 10.1097/md.0000000000030390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Total pancreatectomy (TP) is performed for diseases of the entire pancreas. However, reluctance remains regarding TP because of the fear of high morbidity and mortality. Our retrospective study aimed to evaluate the postoperative outcomes of TP performed at a high-volume single center and to identify the risk factors associated with major morbidities and mortality after TP. A total of 142 patients who underwent elective TP at Samsung Medical Center between 1995 and 2015 were included. TP was usually planned before surgery or decided during surgery [one-stage TP], and there were some completion TP cases that were performed to manage tumors that had formed in the remnant pancreas after a previous partial pancreatectomy [2-stage TP]. The differences between the 1-stage and 2-stage TP groups were analyzed. Chronological comparison was also conducted by dividing cases into 2 periods [the early and late period] based on the year TP was performed, which divided the total number of patients to almost half for each period. Among all TP patients, major morbidity occurred in 25 patients (17.6%), the rate of re-admission within 90-days was 20.4%, and there was no in-hospital and 30-days mortality. Between the 1-stage and 2-stage TP groups, most clinical, operative, and pathological characteristics, and postoperative outcomes did not differ significantly. Chronological comparison showed that, although the incidence of complications was higher, hospitalization was shorter due to advanced managements in the late period. The overall survival was improved in the late period compared to the early period, but it was not significant. A low preoperative protein level and N2 were identified as independent risk factors for major morbidity in multivariable analysis. The independent risk factors for poor overall survival were R1 resection, adenocarcinoma, and high estimated blood loss (EBL). TP is a safe and feasible procedure with satisfactory postoperative outcomes when performed at a high-volume center. More research and efforts are needed to significantly improve overall survival rate in the future.
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Affiliation(s)
- Ji Hye Jung
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - So Jeong Yoon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Ok Joo Lee
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
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Suto H, Kamei K, Kato H, Misawa T, Unno M, Nitta H, Satoi S, Kawabata Y, Ohtsuka M, Rikiyama T, Sudo T, Matsumoto I, Hirao T, Okano K, Suzuki Y, Sata N, Isaji S, Sugiyama M, Takeyama Y. Risk factors associated with hypoglycemic events after total pancreatectomy: A nationwide multicenter prospective study in Japan. Surgery 2022; 172:962-967. [PMID: 35820975 DOI: 10.1016/j.surg.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/27/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The number of total pancreatectomy cases have increased worldwide, expanding the need for new insulin products and high-titer pancrelipases. However, the current data that is focused on hypoglycemic events after a total pancreatectomy from large nationwide series are still lacking. This study is aimed to assess the risk factors associated with hypoglycemic events after a total pancreatectomy. METHODS Data were prospectively collected from 216 consecutive patients who underwent total pancreatectomies between August 2015 and December 2017 from 68 Japanese centers. Of the 216 patients, 166 with a follow-up period of 1 year were analyzed. The risk factors for hypoglycemic events at 6 and 12 months (postoperative months 6 and 12) were investigated based on the results of a nationwide multicenter prospective study. RESULTS Of the 166 patients, 57 (34%) and 70 (42%) experienced moderate or severe hypoglycemic events or hypoglycemia unawareness on a monthly basis at postoperative months 6 and 12, respectively. Multivariate analysis revealed that body weight loss after surgery ≥0.3 kg and total cholesterol level ≤136 mg/dL at postoperative month 6, and glycated hemoglobin level ≤8.9% and rapid-acting insulin use at postoperative month 12 were independent risk factors for hypoglycemic events after a total pancreatectomy. There were different independent risk factors depending on the postoperative period. CONCLUSION Patients with body weight loss after surgery, low total cholesterol level, strict glycemic control, and using rapid-acting insulin should be aware of the occurrence of hypoglycemic events after their total pancreatectomy. In order to prevent hypoglycemic events after a total pancreatectomy, we need to consider optimal nutritional and glycemic control according to the postoperative period.
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Affiliation(s)
- Hironobu Suto
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan.
| | - Keiko Kamei
- Department of Surgery, Kindai University, Osaka, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takeshi Sudo
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | | | - Tomohiro Hirao
- Department of Public Health, Kagawa University, Kagawa, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Shuji Isaji
- Director of Mie University Hospital, Mie, Japan
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Jung JH, Yoon SJ, Lee OJ, Shin SH, Heo JS, Han IW. Intraoperative Positive Pancreatic Parenchymal Resection Margin: Is It a True Indication of Completion Total Pancreatectomy after Partial Pancreatectomy for Pancreatic Ductal Adenocarcinoma? Curr Oncol 2022; 29:5295-5305. [PMID: 36005158 PMCID: PMC9406454 DOI: 10.3390/curroncol29080420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/19/2022] [Accepted: 07/26/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Total pancreatectomy (TP) can be performed in cases with positive resection margin after partial pancreatectomy for pancreatic cancer. However, despite complete removal of the residual pancreatic parenchyme, it is questionable whether an actual R0 resection and favorable survival can be achieved. This study aimed to identify the R0 resection rate and postoperative outcomes, including survival, following completion TP (cTP) performed due to intraoperative positive margin. Methods: From 1995 to 2015, 1096 patients with pancreatic ductal adenocarcinoma underwent elective pancreatectomy at the Samsung Medical Center. Among these, 25 patients underwent cTP, which was converted during partial pancreatectomy because of a positive resection margin. To compare survival after R0 resection between the cTP R0 and pancreaticoduodenectomy (PD) R0 cases, propensity score matching was conducted to balance the baseline characteristics. Results: The R0 rate of cTP performed due to intraoperative positive margin was 84% (21/25). The overall 5-year survival rate (5YSR) in the 25 cTP cases was 8%. There was no difference in the 5YSR between the cTP R0 and cTP R1 groups (9.5% versus 0.0%, p = 0.963). However, the 5YSR of the cTP R0 group was significantly lower than that of the PD R0 group (9.5% versus 20.0%, p = 0.022). There was no distinct difference in postoperative complications between the cTP R0 versus cTP R1 and cTP R0 versus PD R0 groups. Conclusions: In cases with intraoperative positive pancreatic parenchymal resection margin, survival after cTP was not favorable. Careful patient selection is needed to perform cTP in such cases.
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Affiliation(s)
| | | | | | | | | | - In-Woong Han
- Correspondence: ; Tel.: +82-2-3410-0772; Fax: +82-2-3410-6980
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29
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Shao W, Lu Z, Xu J, Shi X, Tan T, Xing C, Song J. Effects of Total Pancreatectomy on Survival of Patients With Pancreatic Ductal Adenocarcinoma: A Population-Based Study. Front Surg 2021; 8:804785. [PMID: 34957210 PMCID: PMC8695493 DOI: 10.3389/fsurg.2021.804785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/18/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Total pancreatectomy (TP) seems to be experiencing a renaissance in recent years. In this study, we aimed to determine the long-term survival of pancreatic ductal adenocarcinoma (PDAC) patients who underwent TP by comparing with pancreaticoduodenectomy (PD), and formulate a nomogram to predict overall survival (OS) for PDAC individuals following TP. Methods: Patients who were diagnosed with PDAC and received PD (n = 5,619) or TP (n = 1,248) between 2004 and 2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. OS and cancer-specific survival (CSS) of the PD and TP groups were compared using Kaplan-Meier method and log-rank test. Furthermore, Patients receiving TP were randomly divided into the training and validation cohorts. Univariate and multivariate Cox regression were applied to identify the independent factors affecting OS to construct the nomogram. The performance of the nomogram was measured according to concordance index (C-index), calibration plots, and decision curve analysis (DCA). Results: There were no significant differences in OS and CSS between TP and PD groups. Age, differentiation, AJCC T stage, radiotherapy, chemotherapy, and lymph node ratio (LNR) were identified as independent prognostic indicators to construct the nomogram. The C-indexes were 0.67 and 0.69 in the training and validation cohorts, while 0.59 and 0.60 of the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system. The calibration curves showed good uniformity between the nomogram prediction and actual observation. DCA curves indicated the nomogram was preferable to the AJCC staging system in terms of the clinical utility. A new risk stratification system was constructed which could distinguish patients with different survival risks. Conclusions: For PDAC patients following TP, the OS and CSS are similar to those who following PD. We developed a practical nomogram to predict the prognosis of PDAC patients treated with TP, which showed superiority over the conventional AJCC staging system.
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Affiliation(s)
- Weiwei Shao
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhenhua Lu
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingyong Xu
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolei Shi
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Tianhua Tan
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Cheng Xing
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinghai Song
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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30
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Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2021; 99:745-756. [PMID: 34794902 DOI: 10.1016/j.cireng.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.
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31
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Loos M, Al-Saeedi M, Hinz U, Mehrabi A, Schneider M, Berchtold C, Müller-Stich BP, Schmidt T, Kulu Y, Hoffmann K, Strobel O, Hackert T, Büchler MW. Categorization of Differing Types of Total Pancreatectomy. JAMA Surg 2021; 157:120-128. [PMID: 34787667 DOI: 10.1001/jamasurg.2021.5834] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Comparability of morbidity and mortality rates after total pancreatectomy (TP) reported by different surgical centers is limited. Procedure-specific differences, such as the extent of resection, including additional vascular or multivisceral resections, are rarely acknowledged when postoperative outcomes are reported. Objectives To evaluate postoperative outcomes after TP and categorize different types of TP based on the extent, complexity, and technical aspects of each procedure. Design, Setting, and Participants This single-center study included a retrospective cohort of 1451 patients who had undergone TP between October 1, 2001, and December 31, 2020. Each patient was assigned to 1 of the following 4 categories that reflect increasing levels of procedure-related difficulty: standard TP (type 1), TP with venous resection (type 2), TP with multivisceral resection (type 3), and TP with arterial resection (type 4). Postoperative outcomes among the groups were compared. Main Outcomes and Measures Categorization of different types of TP based on the procedure-related difficulty and differing postoperative outcomes. Results Of the 1451 patients who had undergone TP and were included in the analysis, 840 were men (57.9%); median age was 64.9 (IQR, 56.7-71.7) years. A total of 676 patients (46.6%) were assigned to type 1, 296 patients (20.4%) to type 2, 314 patients (21.6%) to type 3, and 165 patients (11.4%) to type 4 TP. A gradual increase in surgical morbidity was noted by TP type (type 1: 255 [37.7%], type 2: 137 [46.3%], type 3: 178 [56.7%], and type 4: 98 [59.4%]; P < .001), as was noted for median length of hospital stay (type 1: 14 [IQR, 10-19] days, type 2: 16 [IQR, 12-23] days, type 3: 17 [IQR, 13-29] days, and type 4: 18 [IQR, 13-30] days; P < .001), and 90-day mortality (type 1: 23 [3.4%], type 2: 17 [5.7%], type 3: 29 [9.2%], and type 4: 20 [12.1%]; P < .001). In the multivariable analysis, type 3 (TP with multivisceral resection) and type 4 (TP with arterial resection) were independently associated with an increased 90-day mortality rate. Conclusions and Relevance The findings of this study suggest there are significant differences in postoperative outcomes when the extent, complexity, and technical aspects of the procedure are considered. Classifying TP into 4 different categories may allow for better postoperative risk stratification as well as more accurate comparisons in future studies.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Tumor, and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
| | - Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General Surgery, Vienna University Hospital, Vienna, Austria
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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32
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Salvia R, Burelli A, Perri G, Marchegiani G. State-of-the-art surgical treatment of IPMNs. Langenbecks Arch Surg 2021; 406:2633-2642. [PMID: 34738168 PMCID: PMC8803623 DOI: 10.1007/s00423-021-02349-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 12/28/2022]
Abstract
Background A “pandemic” of incidentally discovered pancreatic cyst neoplasms (PCNs) is ongoing. Among PCNs, intraductal papillary mucinous cystic neoplasms (IPMNs) are the most common and with their complex biology could represent a precursor lesion of pancreatic cancer. Although multiple guidelines exist to guide their treatment, there are still many “gray areas” on indications for surgery for IPMNs. Methods The current indications for surgery of IPMNs were reappraised, considering potential discrepancies between available evidence and guidelines policies. The practice at a high-volume center for the diagnosis and treatment of PCN was presented and discussed. Results Most IPMNs do not and will never require surgery, as they won’t progress to malignancy. The current literature is solid in identifying high-grade dysplasia (HGD) as the right and timely target for IPMN resection, but how to precisely assess its presence remains controversial and guidelines lack of accuracy in this regard. Multiple tumorigenic pathways of progression of IPMNs exist, and their knowledge will likely lead to more accurate tests for malignancy prediction in the future. Conclusions The surgical management of IPMNs still is a matter of debate. Indication for resection should be considered only in highly selected cases with the ideal target of HGD. Clinicians should critically interpret the guidelines’ indications, refer to a multidisciplinary team discussion, and always consider the outcome of an adequate counselling with the patient.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Anna Burelli
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy.
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, Verona University Hospital (Policlinico G.B. Rossi), Piazzale Scuro 10, 37134, Verona, Italy.
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Rom H, Tamir S, Van Vugt JLA, Berger Y, Perl G, Morgenstern S, Tovar A, Brenner B, Benchimol D, Kashtan H, Sadot E. Sarcopenia as a Predictor of Survival in Patients with Pancreatic Adenocarcinoma After Pancreatectomy. Ann Surg Oncol 2021; 29:1553-1563. [PMID: 34716836 DOI: 10.1245/s10434-021-10995-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether sarcopenia can potentially predict worse survival after resection of pancreatic ductal adenocarcinoma. BACKGROUND Sarcopenia is correlated with poor outcomes in hepatopancreatobiliary malignancies, but the relationship of both its qualitative and quantitative features with patient survival after pancreatectomy has not been investigated in a western population. PATIENTS AND METHODS Preoperative cross-sectional computed tomography scans of consecutive patients who underwent pancreatectomy in 2005-2017 were evaluated for skeletal muscle index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR). Sex-specific categorical cut-offs were determined. Findings were correlated with outcome. RESULTS The study included 111 patients, 47% of whom were female, with a median age of 67 years (range: 35-87 years), and median body mass index of 23 kg/m2 (range: 16-40 kg/m2); 77% had a Whipple procedure and 66% received adjuvant chemotherapy. Low SMI correlated with poor overall survival (OS) (P = 0.007), disease-specific survival (DSS) (P = 0.006), and recurrence-free survival (RFS) (P = 0.01). High IMAC correlated with poor OS (P = 0.04). Patients with high IMAC tended to have a shorter DSS (P = 0.09), with no correlation with RFS (P = 0.6). VSR was not associated with survival. Multivariable analysis yielded an independent association of low SMI with OS (HR = 1.7, 95%CI: 1.1-2.8, P = 0.02), DSS (HR = 1.8, 95%CI: 1.03-3.2, P = 0.04), and RFS (HR = 1.8, 95%CI: 1.1-2.8, P = 0.01), and of high IMAC with OS (HR = 1.9, 95%CI: 1.1-3.1, P = 0.01). CONCLUSION Both qualitative and quantitative measures of skeletal muscle were independently associated with impaired survival in patients with resectable PDAC. Sarcopenia might serve as an early radiographic surrogate of aggressive tumor behavior, with potential implications for clinical decision-making and future study.
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Affiliation(s)
- Hadass Rom
- Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomit Tamir
- Department of Radiology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeroen L A Van Vugt
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Yael Berger
- Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gali Perl
- Department of Oncology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Sara Morgenstern
- Institute of Pathology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Ana Tovar
- Institute of Pathology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Baruch Brenner
- Department of Oncology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Daniel Benchimol
- Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
| | - Hanoch Kashtan
- Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Sadot
- Department of Surgery, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Winer A, Dotan E. Treatment Paradigms for Older Adults with Pancreatic Cancer: a Nuanced Approach. Curr Treat Options Oncol 2021; 22:104. [PMID: 34596801 DOI: 10.1007/s11864-021-00892-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2021] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is increasing in incidence in the USA. This disease disproportionately affects older adults, and as the percentage of adults > 65 years old increases with the aging of the baby boomers, the prevalence is expected to rise over the coming decade. These patients are often more susceptible to disease-related symptoms and have less ability to withstand both cancer and treatment-related side effects. Therefore, it is imperative that treating physicians thoughtfully consider their recommended treatment approach towards this vulnerable patient population. This review focuses on the current state of research of older adults with pancreatic adenocarcinoma, highlighting deficiencies in the representation of this patient population in clinical trials. It is vital that the treating physicians take a nuanced approach towards therapy of localized and metastatic disease in geriatric patients. A one size fits all treatment algorithm is no longer appropriate in any cancer patient, let alone the elders who are particularly vulnerable to developing treatment-related toxicities. To help guide therapy decisions, it is important to perform a comprehensive geriatric assessment which may uncover unexpected frailty and lead to a change in the recommended treatment approach. In this way, we can support older adults during therapy for this aggressive malignancy and provide optimal care.
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Affiliation(s)
- Arthur Winer
- Department of Medical Oncology, Inova Schar Cancer Institute, 8081 Innovation Park Drive, Fairfax, VA, 22031, USA.
| | - Efrat Dotan
- Department of Medical Oncology, Fox Chase Cancer, Philadelphia, PA, USA
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35
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Casadei R, Ricci C, Ingaldi C, Alberici L, Minni F. Contemporary indications for upfront total pancreatectomy. Updates Surg 2021; 73:1205-1217. [PMID: 34390466 DOI: 10.1007/s13304-021-01145-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.
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Affiliation(s)
- Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy. .,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Claudio Ricci
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero Universitaria di Bologna, Via Massarenti n.9, 40138, Bologna, Italy.,Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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36
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Salvia R, Lionetto G, Perri G, Malleo G, Marchegiani G. Total pancreatectomy and pancreatic fistula: friend or foe? Updates Surg 2021; 73:1231-1236. [PMID: 34363601 PMCID: PMC8397676 DOI: 10.1007/s13304-021-01130-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Abstract
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
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Affiliation(s)
- Roberto Salvia
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy.
| | - Gabriella Lionetto
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giampaolo Perri
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
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Crippa S, Belfiori G, Tamburrino D, Partelli S, Falconi M. Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground. Updates Surg 2021; 73:1219-1229. [PMID: 34331677 DOI: 10.1007/s13304-021-01141-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/23/2021] [Indexed: 12/23/2022]
Abstract
The extension of a partial pancreatectomy up to total pancreatectomy because of positive neck margin examined at intraoperative frozen section (IFS) analysis is an accepted procedure in modern pancreatic surgery with good accuracy. The goal of this practice is to improve the rate of radical (R0) resection in malignant tumors, mainly pancreatic ductal adenocarcinoma (PDAC), and to completely resect pre-invasive neoplasms such as intraductal papillary mucinous neoplasms (IPMNs). In the setting of IPMNs there is a consensus for pancreatic re-resection when high-grade dysplasia and invasive cancer are present at the neck margin. The presence of denudation is another indication for further resection in IPMNs. The role of IFS analysis in the management of pancreatic cancer is more debated. The presence of a positive intraoperative transection margin can be considered the surrogate of a biologically aggressive disease associated with a poorer prognosis. There are conflicting data regarding possible advantages of pancreatic re-resection up to total pancreatectomy, and the lack of randomized trials comparing different strategies does not offer a definitive answer. The goal of this review is to provide an up-to-date overview of the role IFS analysis of pancreatic margin and of pancreatic re-resection up to total pancreatectomy considering different pancreatic tumors.
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Affiliation(s)
- Stefano Crippa
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giulio Belfiori
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Stefano Partelli
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy. .,Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy. .,Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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38
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Total pancreatectomy sequelae and quality of life: results of islet autotransplantation as a possible mitigation strategy. Updates Surg 2021; 73:1237-1246. [PMID: 34319573 DOI: 10.1007/s13304-021-01129-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022]
Abstract
Total pancreatectomy (TP) is a procedure weighed down not only by postoperative morbidity and mortality but also by long-term effects as a consequence of endocrine and exocrine pancreatic insufficiency. While the latter is now managed quite effectively with pancreatic enzyme replacement therapy, the former remains a challenge. The diabetes resulting after TP, with the complete loss of endogenous insulin and contraregulatory hormones, is characterized by important glycemic variations and is, therefore, frequently referred to as "brittle diabetes". One method to reduce the impact of brittle diabetes in patients undergoing TP is the re-infusion of autologous pancreatic islets isolated from the resected pancreas. Indications to islet autotransplantation (IAT), originally described for patients undergoing TP for chronic pancreatitis, have since been extended to selected patients with other benign and malignant diseases of pancreas. This review recaps on the literature regarding long-term postoperative complications, their impact on quality of life after TP and the role of IAT.
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Suto H, Kamei K, Kato H, Misawa T, Unno M, Nitta H, Satoi S, Kawabata Y, Ohtsuka M, Rikiyama T, Sudo T, Matsumoto I, Hirao T, Okano K, Suzuki Y, Sata N, Isaji S, Sugiyama M, Takeyama Y. Diabetic control and nutritional status up to 1 year after total pancreatectomy: a nationwide multicentre prospective study. Br J Surg 2021; 108:e237-e238. [PMID: 33821972 DOI: 10.1093/bjs/znab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/20/2021] [Accepted: 02/18/2021] [Indexed: 01/09/2023]
Affiliation(s)
- H Suto
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - K Kamei
- Department of Surgery, Kindai University, Osaka, Japan
| | - H Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - T Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - M Unno
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - H Nitta
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | - S Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Y Kawabata
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Shimane, Japan
| | - M Ohtsuka
- Department of General Surgery, Chiba University, Chiba, Japan
| | - T Rikiyama
- Department of Surgery, Saitama Medical Centre, Jichi Medical University, Saitama, Japan
| | - T Sudo
- Department of Surgery, Kure Medical Centre and Chugoku Cancer Centre, Hiroshima, Japan
| | - I Matsumoto
- Department of Surgery, Kindai University, Osaka, Japan
| | - T Hirao
- Department of Public Health, Kagawa University, Kagawa, Japan
| | - K Okano
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - Y Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - N Sata
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - S Isaji
- Director of Mie University Hospital, Mie, Japan
| | - M Sugiyama
- Director of Tokyo Rosai Hospital, Tokyo, Japan
| | - Y Takeyama
- Department of Surgery, Kindai University, Osaka, Japan
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40
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Hempel S, Oehme F, Tahirukaj E, Kolbinger FR, Müssle B, Welsch T, Weitz J, Distler M. More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021; 28:8309-8317. [PMID: 34169383 PMCID: PMC8590996 DOI: 10.1245/s10434-021-10292-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/27/2021] [Indexed: 11/24/2022]
Abstract
Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10292-8.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ermal Tahirukaj
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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De Pastena M, Esposito A, Salvia R. The role of the robot-assisted procedure during total pancreatectomy: a viewpoint. Hepatobiliary Surg Nutr 2021; 10:405-406. [PMID: 34159176 DOI: 10.21037/hbsn-21-83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
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Paik KY, Chung JC. Reappraisal of clinical indication regarding total pancreatectomy: can we do it for the risky gland? Langenbecks Arch Surg 2021; 406:1903-1908. [PMID: 34018039 DOI: 10.1007/s00423-021-02208-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/17/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although total pancreatectomy (TP) is performed at an increasing rate at major pancreatic centers, there is still debate regarding its indications and outcomes. This study aims to analyze the indications and outcomes of TP using our retrospective data. METHODS We conducted a retrospective study on patients who underwent TP between January 2009 and December 2019 at two academic hospitals using data collected. Preoperative data, including demographics and clinical picture, operative details, and postoperative data, were collected and analyzed. Conventional indications of TP included positive margin on the neck, lesion of the central part of the pancreas, and diffuse lesions of the whole pancreas. The classification of the risky gland included pancreas remnants, which had higher risk for pancreaticoenterostomy after pancreatic head resection. RESULTS During the study periods, a total of 72 TP were performed for benign and malignant pancreatic diseases. After excluding six TP undergone due to trauma or complication after partial pancreatectomy, 64 patients were grouped into 47 patients with existing conventional indications and 17 patients with predicted risky anastomosis. There was no significant difference in clinical data and surgical results between the conventional indication group and the risky gland group. Thirty-day major morbidity and mortality was 9.4% and 0%, respectively. Ninety-day mortality rate was 1.4% (n=1, conventional group), with the median follow-up length of 21.5 months. Overall 5-year survival rate was 67.7% for the total participants: 87.5% for the risk gland group and 57.9% for the conventional group. There was no significant difference in between the two groups. CONCLUSIONS Total pancreatectomy appears to be a viable option for risky glands in terms of surgical safety.
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Affiliation(s)
- Kwang Yeol Paik
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, #10,63-ro, Yeongdengpo-gu, Seoul, 07345, South Korea.
| | - Jun Chul Chung
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Bucheon Soonchunhyang Hospital, Soonchunhyang University of Korea College of Medicine, Asan, South Korea
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43
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Kauffmann EF, Napoli N, Genovese V, Ginesini M, Gianfaldoni C, Vistoli F, Amorese G, Boggi U. Feasibility and safety of robotic-assisted total pancreatectomy: a pilot western series. Updates Surg 2021; 73:955-966. [PMID: 34009627 PMCID: PMC8184722 DOI: 10.1007/s13304-021-01079-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 01/04/2023]
Abstract
This study was designed to demonstrate non-inferiority of robot-assisted total pancreatectomy (RATP) to open total pancreatectomy (OPT) based on an intention-to-treat analysis, having occurrence of severe post-operative complications (SPC) as primary study endpoint. The two groups were matched (2:1) by propensity scores. Assuming a rate of SPC of 22.5% (non-inferiority margin: 15%; α: 0.05; β: 0.20; power: 80%), a total of 25 patients were required per group. During the study period (October 2008–December 2019), 209 patients received a total pancreatectomy. After application of exclusion and inclusion criteria, matched groups were extracted from an overall cohort of 132 patients (OPT: 107; RATP: 25). Before matching, the two groups were different with respect to prevalence of cardiac disease (24.3% versus 4.0%; p = 0.03), presence of jaundice (45.8% versus 12.0%; p = 0.002), presence of a biliary drainage (23.4% versus 0; p = 0.004), history of weight loss (28.0% versus 8.0%; p = 0.04), and vein involvement (55.1% versus 28.0%) (p = 0.03). After matching, the two groups (OTP: 50; RATP: 25) were well balanced. Regarding primary study endpoint, SPC developed in 13 patients (26.0%) after OTP and in 6 patients (24.0%) after RATP (p = 0.85). Regarding secondary study endpoints, RATP was associated with longer median operating times [475 (408.8–582.5) versus 585 min (525–637.5) p = 0.003]. After a median follow-up time of 23.7 months (10.4–71), overall survival time [22.6 (11.2–81.2) versus NA (27.3–NA) p = 0.006] and cancer-specific survival [22.6 (11.2–NA) versus NA (27.3–NA) p = 0.02] were improved in patients undergoing RATP. In carefully selected patients, robot-assisted total pancreatectomy is non-inferior to open total pancreatectomy regarding occurrence of severe post-operative complications.
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Affiliation(s)
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Valerio Genovese
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy-Arterial Resection, Arterial Divestment and Total Pancreatectomy. Cancers (Basel) 2021; 13:cancers13081818. [PMID: 33920314 PMCID: PMC8068970 DOI: 10.3390/cancers13081818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Aggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC. Abstract Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.
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45
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Wundsam HV, Rösch CS, Kirchweger P, Fischer I, Weitzendorfer M, Rumpold H, Függer R. Long-Term Quality of Life after Pancreatic Surgery for Intraductal Papillary Mucinous Neoplasm. Eur Surg Res 2021; 62:80-87. [PMID: 33827087 DOI: 10.1159/000515459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/25/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intraductal papillary mucinous neoplasms (IPMNs) represent the most common precancerous cystic lesions of the pancreas. The aim of our study was to investigate if resection for non-invasive IPMNs alters quality of life (QoL) in a long-term follow-up. METHODS Patients (n = 50) included in the analysis were diagnosed and resected from 2010 to 2016. QoL was assessed at a median of 5.5 years after resection. At that point in time, the current QoL as well as the QoL before resection was evaluated retrospectively. The standardised European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Pancreatic Cancer (EORTC QLQ - PAN26) was applied for the QoL assessment. RESULTS After a median of 66 months postoperatively, the total QoL score significantly worsened (92.13 vs. 88.04, p = 0.020, maximum achievable score = 100) for patients (median age at surgery 68.0 years), mostly due to digestive symptoms. During the same follow-up period, median Eastern Cooperative Oncology Group (ECOG) performance status did not worsen (p = 0.003). CONCLUSIONS Long-term QoL statistically significantly worsened after pancreatic resection for IPMN. The extent of worsening, however, was small, and QoL still remained excellent. Therefore, resection in cases of IPMN is appropriate, if indicated carefully.
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Affiliation(s)
| | | | | | - Ines Fischer
- Department of Surgery, Ordensklinikum Linz, Linz, Austria
| | | | - Holger Rumpold
- Department of Gastrointestinal Cancer Center, Ordensklinikum Linz, Linz, Austria
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Shaw K, Thomas AS, Rosario V, Kwon W, Schrope BA, Sugahara K, Chabot JA, Genkinger JM, Kluger MD. Long term quality of life amongst pancreatectomy patients with diabetes mellitus. Pancreatology 2021; 21:501-508. [PMID: 33509685 DOI: 10.1016/j.pan.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/01/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreatogenic diabetes is common after pancreatectomy, and the impact on quality of life (QOL) is poorly understood. The objective of this study was to investigate QOL between diabetic and non-diabetic patients at least five years after pancreatectomy. METHODS Patients were recruited from a prospectively maintained institutional database. Participants were administered the Audit of Diabetes-Dependent Quality of Life (ADDQOL). Quality of life was compared between diabetics and non-diabetics using validated European Organization for Research and Treatment of Cancer questionnaires. RESULTS 80 individuals completed surveys. 55% were female, 80% non-Hispanic white, 44% underwent Whipple, 48% were cystic neoplasms and 39% were adenocarcinoma. Diabetic patients (42.5%) reported comparable EORTC QLQ-C30 and Pan26 scores to non-diabetic patients. Pre-operative diabetic patients reported more dyspnea (p = 0.02) and greater pain (p = 0.02) than new-onset diabetics. Diabetic patients reported an overall ADDQOL quality of life score 'very good' (IQR: excellent, good) though felt life would be much better without diabetes (IQR: very much better, little better). While operation type was not influential, patients diagnosed with cystic neoplasms were almost twice as likely as those with other pathologies to report that life would be much better without diabetes (p < 0.01). CONCLUSION At a median of 9.3 years from pancreatic surgery, ADDQoL scores of patients were similar to cohorts of non-pancreatogenic diabetics in the general population. Patients without cancer were more likely to report that diabetes affected their overall QOL, regardless of operation. This study provides nuanced understanding of long-term QOL to improve the informed consent process and post-operative long-term care.
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Affiliation(s)
- Kaitlin Shaw
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Vilma Rosario
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Wooil Kwon
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Beth A Schrope
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Kazuki Sugahara
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - John A Chabot
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Jeanine M Genkinger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
| | - Michael D Kluger
- Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
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Capretti G, Donisi G, Gavazzi F, Nappo G, Pansa A, Piemonti L, Zerbi A. Total pancreatectomy as alternative to pancreatico-jejunal anastomosis in patients with high fistula risk score: the choice of the fearful or of the wise? Langenbecks Arch Surg 2021; 406:713-719. [PMID: 33783612 DOI: 10.1007/s00423-021-02157-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE Patients with fistula risk score (FRS) ≥7 are at the highest risk of developing clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement on the management of this subpopulation. The primary outcome of the study was the definition of the role of intraoperative completion pancreatectomy (ICP) in patients at high risk for CR-POPF, as an alternative to high-risk pancreaticoduodenectomy (PD). METHODS This is an observational study set in a single tertiary referral center. Patients scheduled for PD in our center between 2010 and 2019 with FRS ≥7 were included in the study. Data were prospectively collected. RESULTS A total of 738 patients were scheduled for between 2010 and 2019, and 62 had FRS ≥7. Thirty-five patients were managed with PD and pancreatico-jejunal anastomosis (group A), and 27 with ICP (group B). Overall complication rate was significantly higher in group A than group B (95 versus 59%; p=0.005) and there was a not significantly higher rate of major complications (Clavien-Dindo ≥3) (43 versus 26%; p=0.192). In group A, 49% of patients had a CR-POPF. Median post-operative length of stay was 15 days in group A and 12 in group B (p=0.043). Readmission was observed only in group A (26%). In multivariate analysis, PD was an independent predictive factor of major post-operative morbidity (RR 9.27; CI 1.74-49.31). No patients in either group suffered major adverse events related to endocrine and exocrine insufficiency. CONCLUSION In high-FRS patients, ICP has good short-term outcomes relative to PD without major long-term events related to endocrine and exocrine insufficiency. ICP could be considered as a feasible alternative in selected cases.
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Affiliation(s)
- Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy. .,Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy.
| | - Greta Donisi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Andrea Pansa
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
| | - Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, MI, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy.,Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
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Oh MY, Kim EJ, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, Kwon W, Jang JY. Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy. Ann Surg Treat Res 2021; 100:200-208. [PMID: 33854989 PMCID: PMC8019983 DOI: 10.4174/astr.2021.100.4.200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP. Methods Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year. Results Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted. Conclusion Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.
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Affiliation(s)
- Moon Young Oh
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Joo Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Jin Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Latenstein AEJ, Mackay TM, Beane JD, Busch OR, van Dieren S, Gleeson EM, Koerkamp BG, van Santvoort HC, Wellner UF, Williamsson C, Tingstedt B, Keck T, Pitt HA, Besselink MG. The use and clinical outcome of total pancreatectomy in the United States, Germany, the Netherlands, and Sweden. Surgery 2021; 170:563-570. [PMID: 33741182 DOI: 10.1016/j.surg.2021.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/16/2021] [Accepted: 02/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Total pancreatectomy has high morbidity and mortality and differences among countries are currently unknown. This study compared the use and postoperative outcomes of total pancreatectomy among 4 Western countries. METHODS Patients who underwent one-stage total pancreatectomy were included from registries in the United States, Germany, the Netherlands, and Sweden (2014-2018). Use of total pancreatectomy was assessed by calculating the ratio total pancreatectomy to pancreatoduodenectomy. Primary outcomes were major morbidity (Clavien Dindo ≥3) and in-hospital mortality. Predictors for the primary outcomes were assessed in multivariable logistic regression analyses. Sensitivity analysis assessed the impact of volume (low-volume <40 or high-volume ≥40 pancreatoduodenectomies annually; data available for the Netherlands and Germany). RESULTS In total, 1,579 patients underwent one-stage total pancreatectomy. The relative use of total pancreatectomy to pancreatoduodenectomy varied up to fivefold (United States 0.03, Germany 0.15, the Netherlands 0.03, and Sweden 0.15; P < .001). Both the indication and several baseline characteristics differed significantly among countries. Major morbidity occurred in 423 patients (26.8%) and differed (22.3%, 34.9%, 38.3%, and 15.9%, respectively; P < .001). In-hospital mortality occurred in 85 patients (5.4%) and also differed (1.8%, 10.2%, 10.8%, 1.9%, respectively; P < .001). Country, age ≥75, and vascular resection were predictors for in-hospital mortality. In-hospital mortality was lower in high-volume centers in the Netherlands (4.9% vs 23.1%; P = .002), but not in Germany (9.8% vs 10.6%; P = .733). CONCLUSION Considerable differences in the use of total pancreatectomy, patient characteristics, and postoperative outcome were noted among 4 Western countries with better outcomes in the United States and Sweden. These large, yet unexplained, differences require further research to ultimately improve patient outcome.
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Affiliation(s)
- Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/anouklatenstein
| | - Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands. https://twitter.com/tarammackay
| | - Joal D Beane
- Department of Surgical Oncology, Ohio State University, Columbus, OH
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein and University Medical Center Utrecht Cancer Center, the Netherlands
| | - Ulrich F Wellner
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Sweden
| | - Tobias Keck
- DGAV StuDoQ
- Pancreas and Clinic of Surgery, UKSH Campus Lübeck, Germany
| | - Henry A Pitt
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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50
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Minimal main pancreatic duct dilatation in small branch duct intraductal papillary mucinous neoplasms associated with high-grade dysplasia or invasive carcinoma. HPB (Oxford) 2021; 23:468-474. [PMID: 32912834 DOI: 10.1016/j.hpb.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to determine the incidence of high-grade dysplasia (HGD) or invasive carcinoma in patients with small branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). METHODS 923 patients who underwent surgical resection for an IPMN were identified. Sendai-negative patients were identified as those without history of pancreatitis or jaundice, main pancreatic duct size (MPD) <5 mm, cyst size <3 cm, no mural nodules, negative cyst fluid cytology for adenocarcinoma, or serum carbohydrate antigen 19-9 (CA 19-9) <37 U/L. RESULTS BD-IPMN was identified in 388 (46.4%) patients and 89 (22.9%) were categorized as Sendai-negative. Overall, 68 (17.5%) of BD-IPMN had HGD and 62 (16.0%) had an associated invasive-carcinoma. Among the 89 Sendai-negative patients, 12 (13.5%) had IPMNs with HGD and only one patient (1.1%) had invasive-carcinoma. Of note, older age (OR 1.13, 95% CI 1.03-1.23; P = 0.008) and minimal dilation of MPD (OR 11.3, 95% CI 2.40-53.65; P = 0.002) were associated with high-risk disease in Sendai-negative patients after multivariable risk adjustment. CONCLUSION The risk of harboring a high-risk disease remains low in small BD-IPMNs. However, Sendai-negative patients who are older than 65 years old and those with minimal dilation of MPD (3-5 mm) are at greater risk of high-risk lesions and should be given consideration to be included as a "worrisome feature" in a future guidelines update.
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