• Humans
• Male
• Female
• Adenocarcinoma/mortality
• Adenocarcinoma/therapy
• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Middle Aged
• Chemotherapy, Adjuvant
• Ampulla of Vater/surgery
• Ampulla of Vater/pathology
• Aged
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/therapy
• Pancreatic Neoplasms/surgery
• Common Bile Duct Neoplasms/mortality
• Common Bile Duct Neoplasms/surgery
• Common Bile Duct Neoplasms/pathology
• Common Bile Duct Neoplasms/therapy
• Neoplasm Staging
• India
• Treatment Outcome
• Risk Factors
• Gemcitabine
• Time Factors
• Deoxycytidine/analogs & derivatives
• Deoxycytidine/therapeutic use
• Pancreatectomy/adverse effects
• Risk Assessment
• Adult

• Exercise
• Nutrition
• Outcomes
• Pancreaticoduodenectomy
• Quality

• Humans
• Pancreatic Neoplasms/surgery
• Preoperative Exercise
• Postoperative Complications
• Length of Stay
• Treatment Outcome
• Preoperative Care
• Pancreatectomy

• Humans
• Pancreatectomy
• Male
• Female
• Retrospective Studies
• Pancreatic Neoplasms/surgery
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/therapy
• Middle Aged
• Aged
• Treatment Outcome
• Combined Modality Therapy
• Neoadjuvant Therapy
• Postoperative Complications/epidemiology
• Adult

• Male
• Humans
• Female
• Pancreaticoduodenectomy/adverse effects
• Patient Satisfaction
• Hospitals, Teaching
• Surveys and Questionnaires
• Length of Stay
• Postoperative Complications/etiology

• 21.R7.INV.CB.UOSA.6.2 PanKind, The Australian Pancreatic Cancer Foundation
• 2021009 National Health and Medical Research Council
• 49358025 Flinders Foundation
• Flinders University

• Human Development Index (HDI)
• demographic shift
• global pancreatic cancer burden
• pancreatic cancer gender disparity
• predictive trends based on GLOBOCAN 2020

• Female
• Humans
• Aged
• Incidence
• Global Health
• Databases, Factual
• Social Class
• Pancreatic Neoplasms/epidemiology

• India
• chemotherapy
• pancreatic cancer
• review
• systemic therapy

• Animals
• Carcinogenesis/genetics
• Carcinoma, Pancreatic Ductal/genetics
• Carcinoma, Pancreatic Ductal/pathology
• Cell Movement/genetics
• Cell Proliferation/genetics
• Gene Expression Regulation, Neoplastic
• Genes, Tumor Suppressor
• Humans
• Neoplasm Metastasis
• Pancreatic Neoplasms/genetics
• Pancreatic Neoplasms/pathology
• Tumor Microenvironment/genetics

• Albumin-globulin ratio
• Pancreatic cancer
• Pancreatoduodenectomy
• Perioperative outcomes
• Prognostication
• Whipple procedure

Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.

To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.

A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models.

Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; P < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; P < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; P < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; P < 0.00001).

Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.

• Outcomes
• Morbidity
• Mortality
• Quality
• Surgery
• Recovery

• Adenocarcinoma/surgery
• Aged
• Humans
• Pancreatectomy
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/adverse effects
• Postoperative Complications/etiology
• Quality of Life
• Survival Rate

• borderline resectable
• global perspective
• low to middle income countries
• neoadjuvant therapy
• pancreatic cancer

• morbidity
• outcome
• research

One of the critical steps during pancreatoduodenectomy (PD) procedure lies in identifying the complicated vascular anatomy of the resected area. The blood supply usually stems from branches of the celiac and the superior mesenteric arteries. However, only in 55-79% of surgeries, the anatomy of the blood vessels encountered by the surgeon is considered normal, while in the remaining cases, there are vascular variations that make these surgeries even more challenging. Any change or deviation from the known surgical course of PD makes surgery difficult and can result in an increase in intra/postoperative complications. In order to reduce difficulties encountered during PD, as well as reducing complication rates and improving surgical outcomes, a preliminary design, which includes preoperative identification of anatomical variations, is needed. The most accurate and accessible tool for identifying such variations is computed tomographic angiography (CTA). The aim of this retrospective study is to assess the prevalence of vascular anomalies encountered during PD, and examine whether there is an association between these anomalies and intra/postoperative morbidity and mortality.

A retrospective study over 5 years was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted to PD were reviewed, and all patients with vascular anomalies were included. The types of anatomical variant as well as other information were collected. For statistical purposes, the group of patients with vascular anomalies was compared to a control group with identical demographic characteristics. A statistical analysis on possible association between vascular anomalies and intra/postoperative complications (mainly bleeding) was performed.

During the aforementioned period, 202 patients underwent PD, and in 41 (20.3%) vascular anomalies were identified. The majority of these patients (32/41) had single anatomical variant, where two and three anatomical variants were identified in seven and two patients, respectively. The most common vascular anomaly was replaced right hepatic artery, noticed in 34 patients (83%). The most common indication for PD for both groups (anatomical variant and control group) was pancreas adenocarcinoma (56%). Intraoperative complication, in the form of bleeding, developed in 6/41 patients (14.6%) of the anatomical variant group and none in the control group. Postoperative complication rates, including post- pancreatoduodenectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), intra-abdominal abscess and wound infection were almost identical for both groups. One case of death within 30 days occurred, and it was in the anatomical variant group.

Anatomical vascular anomalies are a common variant encountered during PD, with RRHA being the most common. Although postoperative morbidity and mortality are not affected by the presence of these anomalies, intraoperative bleeding rate is higher in this specific group, thus; a preoperative diagnosis by means of CTA is mandatory.

• Pancreatoduodenectomy
• Post-pancreatoduodenectomy complications
• Post-pancreatoduodenectomy hemorrhage
• Vascular anomalies

• Pancreatoduodenectomy
• Postpancreatoduodenectomy hemorrhage
• Pseudoaneurysm

• Collateral vessel
• Pancreatic cancer
• Pancreatoduodenectomy
• Portal hypertension
• Portal vein involvement
• Vein resection

• morbidity
• mortality
• outcomes
• quality
• surgery

• POPF
• Prediction model
• Whipple

• chemotherapy
• geographic
• morbidity
• mortality
• outcomes
• statistics
• survival

The rapidly increasing burden of cancer in India has profound impacts on health care costs for patients and their families. High out-of-pocket (OOP) expenditure, lack of insurance, and low government expenditure create a vicious cycle, leading to household impoverishment. Complex cancer surgery is now increasingly important for emerging countries; however, little is understood about the macro- and microeconomics of these procedures. After the Lancet Oncology Commission on Global Cancer Surgery, we evaluated the OOP expenditure for patients undergoing pancreatico-duodenectomy (PD) at a government tertiary cancer center in India.

Prospective data from 98 patients who underwent PD between January 2014 and June 2015 were collected and analyzed. The time frame for consideration of expenses, including all preoperative investigations, was from the first hospital visit to the day of discharge. Catastrophic expenditure was calculated by assessing the percentage of households in which OOP health payments exceeded 10% of the total household income.

The mean expenditure for PD by patients was Rs.295,679.57 (US$74,420, purchasing power parity corrected). This amount was significantly higher among those admitted to a private ward and those with complications. Only 29.6% of the patients had insurance coverage. A total of 76.5% of the sample incurred catastrophic expenditure, and 38% of those with insurance underwent financial catastrophe compared with 93% of those without insurance. The percentage of patients facing catastrophic impact was highest among those in semiprivate wards, at 86.7%, followed by those in public and private wards.

The cost of PD is high and is often unaffordable for a majority of India’s population. A review of insurance coverage policies for better coverage must be considered.

• borderline
• borderline resectable pancreatic cancer
• pancreatic cancer
• pancreaticoduodenectomy

• Chemotherapy
• Genetics
• Outcomes
• Pancreas
• Radiation
• Survival

• Enhanced recovery
• Pancreatic cancer resections

• Aggressive surgical resection
• Pancreas
• Solid pseudopapillary tumor

• Pancreatoduodenectomy
• R1 rate
• Resection margin
• Standardised pathology evaluation protocol
• Tumour origin

• High-volume centre
• Low-volume centre
• Outcome
• Pancreaticoduodenectomy

• Extended
• Outcome
• Pancreatectomy
• Survival

• Adult
• Aged
• Cohort Studies
• Databases, Factual
• Disease-Free Survival
• Female
• Humans
• Kaplan-Meier Estimate
• Logistic Models
• Male
• Middle Aged
• Neoplasm Invasiveness/pathology
• Neoplasm Staging
• Pancreatectomy/methods
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/methods
• Practice Guidelines as Topic/standards
• Prognosis
• Retrospective Studies
• Risk Assessment
• Societies, Medical/standards
• Statistics, Nonparametric
• Survival Analysis
• Treatment Outcome
• Pancreatic Neoplasms

• ISGPS definition
• delayed gastric emptying
• pancreatoduodenectomy
• pyloric ring resection

• Duodenal neuroendocrine tumours
• Gastroenteropancreatic neuroendocrine tumours
• India
• Neuroendocrine tumours
• Nonfunctional neuroendocrine tumours
• Pancreatic neuroendocrine tumours
• Surgical outcomes

• Enteral nutrition
• Morbidity
• Parenteral nutrition
• Review
• Therapeutics
• Vomiting

GI cancer is not one cancer but is a term for the group of cancers that affect the digestive system including gastric cancer (GC), colorectal cancer (CRC), hepatocellular carcinoma (HCC), esophageal cancer (EC), and pancreatic cancer (PC). Overall, the GI cancers are responsible for more cancers and more deaths from cancer than any other organ. 5 year survival of these cancers remains low compared to western world. Unlike the rest of the world where organ based specialities hepatobiliary, pancreatic, colorectal and esophagogastric exist, these cancers are managed in India by either a gastrointestinal surgeons, surgical oncologist, or a general surgeon with varying outcomes. The aim of this review was to collate data on GI cancers in indian continent. In colorectal cancers, data from tertiary care centres identifies the unique problem of mucinous and signet colorectal cancer. Results of rectal cancer resection in terms of technique (intersphincteric resection, extralevator aper, minimal invasive approach) to be comparable with world literature. However long term outcome and data regarding colon cancers and nationally is needed. Gastric cancer at presentation are advanced and in surgically resected patients, there is need for a trial to compare chemoradiation vs chemotherapy alone to prevent loco regional recurrence. Data on minimal invasive gastric cancer surgery may be sparse for the same reason. Theree is a lot of data on surgical techniques and perioperatve outcomes in pancreatic cancer. There is a high volume of locally advanced gallbladder cancers with efforts on to decide whether neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is better for down staging. Considering GI cancers, a heterogeneous disease with site specific treatment options and variable outcomes, the overall data and outcomes are extremely variable. Young patients with pathology unique to the Indian subcontinent (for example, signet ring rectal cancer, GBCs) need focussed attention. Solution for such pathology needs to come from the Indian continent itself. Joint efforts to improve outcomes for GI cancer can be integrated under the national cancer grid program.

• Colorectal cancers
• India
• gallbladder cancers
• gastric cancers
• pancreatic cancers

• Human Development Index (HDI)
• WHO regions
• demographic shift
• global pancreatic cancer burden
• predictive trends based on GLOBOCAN 2012 database

• Morbidity
• Mortality
• Nomogram
• Outcomes
• Quality
• Surgery

Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure has been described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon’s experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.

• Laparoscopic pancreatoduodenectomy
• Roboticpancreatoduodenectomy
• Minimally invasive pancreatoduodenectomy

Background. Pelvic exenteration (PE) is a morbid procedure. Ours is a rural based cancer center limited trained surgical oncology staff. Hence, this audit was planned to evaluate morbidity and outcomes of all patients undergoing PE at our center. Methods. This is a IRB approved retrospective audit of all patients who underwent PE at our center from January 2010 to August 2013. The toxicity grades were retrospectively assigned according to the CTCAE version 4.02 criteria. Chi-square test was done to identify factors affecting grades 3–5 morbidity. Kaplan Meier survival analysis has been used for estimation of median PFS and OS. Results. 34 patients were identified, with the median age of 52 years (28–73 years). Total, anterior, posterior, and modified posterior exenterations were performed in 4 (11.8%), 5 (14.7%), 14 (41.2%), and 11 (32.4%) patients, respectively. The median time for surgery was 5.5 hours (3–8 hours). The median blood loss was 500 mL (200–4000 mL). CTCAE version 4.02 grades 3-4 toxicity was seen in nine patients (25.7%). The median estimated progression free survival was 31.76 months (25.13–38.40 months). The 2-year overall survival was 97.14%. Conclusion. PE related grades 3–5 morbidity of 25.7% and mortality of 2.9% at our resource limited center are encouraging.