Pancreatectomy For Cancer Research Articles

Impact of Metastatic Pattern on Survival Following Pancreatectomy for Cancer.

The incidence of pancreatic cancer is increasing, and up to 55% of patients present with metastatic disease at the time of diagnosis. Many patients also develop metastatic disease following surgical resection. The impact of metastatic patterns on outcomes has not been described. A retrospective chart review was conducted of patients with pancreatic adenocarcinoma treated at a tertiary care center from 2012 to 2023. Patients who presented with metastatic disease or developed metastatic disease during their treatment course were identified. Univariate analysis was performed to identify factors associated with specific metastatic patterns. Kaplan-Meier survival curves were estimated for metastatic sites and stratified by treatment. Of the 330 patients identified, 192 (58.2%) presented with locoregional disease and underwent curative intent surgery before developing metastases, and 138 (41.8%) presented initially with metastatic disease. Median overall survival (OS) with metastases for all patients was 6 months. For patients who underwent curative intent surgery, OS was significantly worse for those who developed peritoneal metastasis compared to patients who developed other sites of metastases (median OS 5.4 vs. 9.2 months, p = 0.0005). The development of peritoneal metastases after surgery for pancreatic cancer is associated with worse OS compared to other sites of metastatic disease.

The ACS-NSQIP Analysis of Negative Pressure Wound Therapy Following Pancreatectomy for Pancreatic Diagnoses.

Introduction Surgical site infections (SSIs) continue to be a challenging issue among patients undergoing pancreatectomy. Anecdotally, the use of negative pressure wound therapy (NPWT) following pancreatectomy for cancer has been associated with decreased SSIs. The objective of this study was to compare the postoperative outcomes of NPWT and non-NPWT for incisional wound care following distal pancreatectomy or pancreatoduodenectomy for pancreatic diagnoses using a national surgical database. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2005 to 2019 for patients undergoing distal pancreatectomy or pancreaticoduodenectomy for pancreatic diagnoses using primary Current Procedural Terminology (CPT) codes. The primary outcome was surgical site infection rates between NPWT and non-NPWT patient groups. Secondary outcomes include sepsis, septic shock, readmission, and reoperation. Outcomes of interest were compared using multivariate logistic regression. Results A total of 54,457 patients underwent pancreatectomy with 131 receiving NPWT. Multivariate analysis, while accounting for patient characteristics, including wound classification, showed no difference in postoperative superficial SSI, deep SSI, sepsis, septic shock, or readmission between the NPWT and non-NPWT groups. Organ space SSI was higher in the NPWT group (21% vs 12%, p=0.001). Reoperation related to procedure was also highin the NPWT group (14% vs 4.3%, p<0.001). Conclusion The use of NPWT in distal pancreatectomies and pancreatoduodenectomies is associated with increased organ space SSIs and reoperation rates, with no difference in superficial SSI, deep SSI, or readmission. This large sample study shows no significant benefit of using NPWT incisional wound care after pancreatectomy.

Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort.

To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.

Initial Surveillance Imaging after Pancreatectomy for Cancer Is Not Affected By Race or Insurance Status in New York State

Thomas, Alexander S. MD; Sharma, Rahul K. BS; Kwon, Wooil MD, PhD; Schrope, Beth A. MD, FACS; Sugahara, Kazuki MD; Chabot, John A. MD, FACS; Kluger, Michael D. MD, MPH, FACS Author Information

ASO Visual Abstract: Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

ASO Visual Abstract: Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

Although laparoscopic distal pancreatectomy (LDP) versus open approaches (ODP) for pancreatic adenocarcinoma (PDAC) is associated with reduced morbidity, its impact on optimal adjuvant chemotherapy (AC) utilization remains unclear. Furthermore, it is uncertain whether oncologic resection quality markers are equivalent between approaches. The National Cancer Database (NCDB) was queried between 2010 and 2016 for PDAC patients undergoing DP. Effect of LDP vs ODP and institutional case volumes on margin status, hospital stay, 30-day and 90-day mortality, administration of and delay to AC, and 30-day unplanned readmission were analyzed using binary and linear logistic regression. Cox multivariable regression was used to correct for confounders. The search yielded 3411 patients; 996 (29.2%) had LDP and 2415 (70.8%) had ODP. ODP had higher odds of readmission [odds ratio (OR) 1.681, p = 0.01] and longer hospital stay [β 1.745, p = 0.004]. No difference was found for 30-day mortality [OR 1.689, p = 0.303], 90-day mortality [OR 1.936, p = 0.207], and overall survival [HR 1.231, p = 0.057]. The highest-volume centers had improved odds of AC [OR 1.275, p = 0.027] regardless of approach. LDP conferred lower margin positivity [OR 0.581, p = 0.005], increased AC use [3rd quartile: OR 1.844, p = 0.026; 4th quartile; OR 2.144, p = 0.045], and fewer AC delays [4th quartile: OR 0.786, p = 0.045] in higher-volume centers. In selected patients, LDP offers an oncologically safe alternative to ODP for PDAC independent of institutional volume. However, additional oncologic benefit due to optimal AC utilization and lower positive margin rates in higher volume centers suggests that LDP by experienced teams can achieve best possible cancer outcomes.

Long-term Dependency Outcomes in Older Adults Following Hepato-Pancreato-Biliary Surgery for Cancer: A Population-based Analysis.

To evaluate healthcare dependency following hepatopancreato-biliary cancer surgery in older adults (OA). Functional outcomes are central to decisionmaking by OA, but long-term risks of dependency have not been described beyond 1 year in this population. All patients over age 70 undergoing hepatectomy or pancreatec-tomy for cancer between 2007 and 2017 in Ontario were analyzed. Outcomes were 1) receipt of homecare and 2) time at home. Homecare was analyzed with cumulative incidence functions, and time at home with Kaplan-Meier and Cox multivariate models. A total of 902 and 1283 patients underwent hepatectomy and pancreatectomy, respectively. Homecare use was highest (72.3%) in postoperative month-1, decreasing to stabilize between year-1 (25.5%) and year-5 (18.3%). Repeated receipt of homecare was associated with female sex (HR 1.18, 95% CI 1.05-1.32), receipt of adjuvant therapy (HR 1.56, 1.37-1.78), and more recent year of surgery (HR 3.80, 3.05-4.72). The ratio of home nursing care versus personal support services reversed from 68%/26% in year-1, to 29/64% in year-5. High time at home (>350 days) at 1 and 5 years were 40.6% (95% CI 38.5%-42.6%) and 28.1% (25.9%-30.3%), respectively. The ratio of institution-days in acute care versus nursing homes went from 77%/14% in year-1 to 23%/70% in year-5. Low time at home was associated with duodenal (HR 1.45, 1.15-1.70) and pancreas cancer (HR 1.20, 1.02-1.42), and with rural residence (HR 1.24, 1.04-1.48). High time at home was associated with more recent year of surgery (HR 0.84, 0.76-0.93) and perioperative cancer therapy (HR 0.88, 0.78-0.99). Increasing age was neither associated with homecare receipt nor time at home. Following hepatopancreatobiliary cancer surgery, there is a high rate of long-term healthcare dependency for OA. There is an immediate high need for homecare that reaches a new baseline after 6 months, and the majority of OA will have at least 1 year with low time at home, most commonly the first year. These findings can aid in preoperative preparation and transitional care planning.

Exocrine Pancreatic Insufficiency After Pancreatectomy for Malignancy: Systematic Review and Optimal Management Recommendations

BackgroundExocrine pancreatic insufficiency (EPI) occurs when pancreatic enzyme activity in the intestinal lumen is insufficient for normal digestion to occur. The true incidence and diagnosis of EPI after pancreatectomy has not been fully understood and optimized. The aim of this study was to present incidence and diagnostic criteria for EPI after pancreatectomy for cancer and provide a guide for management and optimal therapy in pancreatectomy patients with cancer. MethodsA comprehensive review of the literature with publication dates from 2014 to 2019 was performed. A comprehensive diagnostic and treatment algorithm was then created based on literature review and current treatment options. ResultsIn total, 30 studies were included, 19 combined both pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), 9 for central pancreatectomy, and 2 others. EPI was defined subjectively without definitive testing using any of the established diagnostic studies in the majority of studies 23 (76%). Preoperative EPI was calculated to be 11.52%. Most studies assessed exocrine function at least 6 months postoperatively with four studies extending the follow-up period beyond 12 months. EPI diagnosed postoperatively at 1 month (40.27%), 3 months (30.94%), 6 months (36.06%), and 12 months (34.69%). After PD, the median prevalence of postoperative EPI was 43.14%, CP, the median prevalence was 4.85%, DP, median prevalence of postoperative EPI of 11.94%. ConclusionEPI is a frequent outcome that is often misdiagnosed or under-reported by the patient post-pancreatectomy. Given the increasing overall survival in pancreatectomy patients for cancer, surgeon awareness and assessment is critical to improving patients’ overall quality of life.

Contemporary perioperative outcomes for portal vein resection and reconstruction following pancreaticoduodenectomy for malignancy

Background: Portal vein resection and reconstruction (PVRR) can be technically challenging during pancreatectomy for cancer, but is sometimes necessary with disease involvement of the mesenteric vessels. This study examined if PVRR negatively impacted perioperative outcomes in a modern patient cohort. Methods: All patients who underwent pancreaticoduodenectomy (PD) or total pancreatectomy (TP) from 2010-2014 for invasive malignancy at our center were retrospectively reviewed. Clinicopathologic variables were compared and univariate logistic regression was used to compare outcomes between patients who underwent PVRR and those who did not. Results: During the study period, 309 patients underwent PD or TP for resection of malignancy, with 78 (25.2%) patients requiring PVRR. Primary repair of the defect was the most common method of PVRR (62.8%), followed by end-to-end repair (23.1%), side-to-side repair (5.1%), and autologous vein patch (5.1%). Nonautologous patch repair was used in only 2.6% of cases, with no cases of synthetic graft use. The PVRR group had increased operative time (495±153 vs. 437±130 minutes, p=0.001), decreased formation of pancreatic fistula (10.3% vs. 21.6%, p=0.029), and decreased deep surgical site infection (9.0% vs. 22.1%, p=0.011). There is no difference between groups for all other examined complications, including PV thrombosis (2.6% vs. 1.3%, p=0.603) in short-term follow-up. Conclusions: Most PVRR can be performed primarily, and synthetic material can be avoided entirely with modern techniques. Despite increased operative time, perioperative complications appear to be either unchanged or reduced in PVRR patients. This may be due to increased utilization of neoadjuvant therapy in this group.Tabled 1Comparison of outcomes in patients who underwent PVRR and no PVRR during PD/TP for invasive malignancy.PVRR (N=78)No PV Resection (N=231)P ValueOperative Time (mins)495 ± 153437 ± 1300.001Hospital LOS (days)9.3 ± 3.910.4 ± 6.80.177All Complications36 (46.2%)129 (55.8%)0.150Superficial SSI9 (11.5%)22 (9.5%)0.663Deep SSI7 (9.0%)51 (22.1%)0.011Pancreatic Fistula (grade B or C)8 (10.3%)50 (21.6%)0.029Required Blood Transfusion13 (16.7%)29 (12.6%)0.347PV Thrombus2 (2.6%)3 (1.3%)0.603Reoperation2 (2.6%)9 (3.9%)0.736 Open table in a new tab

Long-term Dependency Outcomes in Older Adults Following Hepatectomy and Pancreatectomy for Cancer: A Population-based Analysis

Long-term Dependency Outcomes in Older Adults Following Hepatectomy and Pancreatectomy for Cancer: A Population-based Analysis

Variation in value among hospitals performing complex cancer operations

BackgroundWhile variation in outcomes has driven centralization of complex cancer surgery, variation in cost and value remains unexplored. We evaluated outcomes relative to cost among hospitals performing esophageal and pancreatic resection for cancer. MethodsUsing 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective esophagectomy and pancreatectomy for cancer from 2014 to 2016. Risk- and reliability-adjusted, price-standardized payments for the surgical episode from admission through 30 days post discharge, as well as risk- and reliability-adjusted complication rates for each hospital, were calculated. Hospitals were separated into quintiles relative to payments and outcomes. Highest-value hospitals were defined as hospitals in the top 2 quartiles for both cost and outcomes. ResultsAmong 11,586 Medicare beneficiaries who underwent a complex oncologic operation between 2014 and 2016, 66% had a pancreatic neoplasm, while 33% had an esophageal neoplasm. Overall, 31.1% patients underwent an operation at a high-value hospital. Among patients who underwent pancreatectomy, the risk-adjusted postoperative complication rate was 31.4% at the lowest-value hospitals vs 22.7% at highest-value hospitals (odds ratio: 0.57, 95% confidence interval 0.47–0.70). The esophagectomy, risk-adjusted postoperative complication rate was 48.3% at lowest-value hospitals versus 29.8% at highest-value hospitals (odds ratio: 0.36, 95% confidence interval 0.27–0.47). The average difference in episode cost of care for an esophagectomy at lowest- versus highest-value hospitals was $5,617; the difference for pancreatectomy was $2,748. ConclusionThere was wide variation in complication rates and average costs among lowest- versus highest-value hospitals performing esophagectomy and pancreatectomy for cancer. Even among highest quality hospitals, wide variation in average episode costs was noted. Surgeons should seek to better understand practice variation to standardize care and decrease variation in outcomes, utilization, and costs.

Long-Term Dependency Outcomes In Older Adults Following Hepatectomy And Pancreatectomy For Cancer: A Population-Based Analysis

Long-Term Dependency Outcomes In Older Adults Following Hepatectomy And Pancreatectomy For Cancer: A Population-Based Analysis

Postoperative deep vein thrombosis after pancreatectomy for cancer: A persistent problem lacking a mechanistic solution

Postoperative deep vein thrombosis after pancreatectomy for cancer: A persistent problem lacking a mechanistic solution

Impact of sarcopenia on outcomes of patients undergoing pancreatectomy: A retrospective analysis of 107 patients.

To evaluate the prevalence of sarcopenia in patients undergoing pancreatic surgery and to examine its impact on the surgical outcomes and survival of patients.Skeletal muscle index (SMI) was measured on preoperative CT. A patient was considered sarcopenic if SMI was <38.5 cm2/m2 for a female or <52.4 cm2/m2 for a male. Postoperative pancreatic fistula (POPF) and severe morbidity (Clavien≥3) were analyzed. Survival of patients with cancer was calculated using the Kaplan–Meier method.In total, 107 consecutive patients were included. Among them, 50 (47%) patients were sarcopenic and 65 (60%) were undernourished. The rates of severe morbidity and mortality were comparable between sarcopenic and nonsarcopenic groups. However, all POPF grade B or C and deaths occurred in the sarcopenic or nonsarcopenic overweight group (BMI > 25) with significantly lengthened hospital stays (P = .003). After pancreatectomy for cancer, 31 (40.2%) patients showed postoperative recurrence and 23 (29.9%) died after a median follow-up of 15 ± 13.5 months. Despite comparable histological types and stages, the median overall and disease-free survivals were lower in sarcopenic patients (16 months vs not reached, P = .02 and 11.1 months vs 22.5 months; P = .04, respectively). The multivariate analysis revealed that, sarcopenia trended to increase the risk of death (HR = 2.04, P = .07).Sarcopenia negatively impacted short- and long-term outcomes in patients undergoing pancreatectomy.

Factors influencing glycemic control following pancreatectomy for cancer

Factors influencing glycemic control following pancreatectomy for cancer

Frailty: A major consideration for short- and long-term outcomes in resected pancreatic cancer.

418 Background: Frailty has been associated with adverse postoperative outcomes. However, little is known about its correlation with survival in resected pancreatic cancer. This study examined the correlation of frailty with postoperative outcomes and survival after pancreatectomy for cancer. Methods: Data from National Surgical Quality Improvement Program (NSQIP) patients (n = 7400) who underwent pancreatectomy between 2011 to 2013. A modified frailty index (mFI) validated for use in NSQIP was used to examine correlations between frailty and postoperative outcomes. California Cancer Registry (CCR) data for patients (n = 4959) who underwent pancreatectomy for cancer between 2000 to 2012 was used to assess the association between the Charlson Comorbidity Index (CCI), as a surrogate for frailty, and overall survival. Results: The distribution of NSQIP patients according to the mFI was 0, 1, 2, 3, 4 in 2797 (37.8%), 3422 (46.2), 1074 (14.5), 104 (1.4) and 3 (0.04) respectively. The patients were divided to non frail (mFI = 0), mildly frail (mFI = 1-2), or severely frail (mFI3 ≥ 3). Overall, 8.7% of patients experienced a grade 4 Clavien complication and 3.1% experienced postoperative mortality. Worsening frailty correlated with an increase in grade 4 Clavien complications (non-frail: 6.3% vs. mildly frail: 9.7% vs. severely frail: 26.2%; p &lt; 0.001) and mortality (1.9% vs. 3.8% vs. 4.7% respectively; p &lt; 0.001). The majority of CCR patients had similarly few comorbidities: CCI: 0, 1, ≥ 2 in 3869 (77.8%), 861 (17.31%) and 243 (4.89%) respectively. Median survival decreased as CCI increased (for CCI 0, 1 and ≥ 2 was 23 vs. 19 vs. 15 months respectively; p &lt; 0.001). Conclusions: Frailty is a powerful correlate of postoperative outcome and survival for resected pancreatic cancer patients and is an important consideration in planning for surgical intervention.

Tu1578 The Incidence of Pancreatic Fistula Following Distal Pancreatectomy for Cancer Rises With Increased Manipulation of the Pancreatic Remnant

Tu1578 The Incidence of Pancreatic Fistula Following Distal Pancreatectomy for Cancer Rises With Increased Manipulation of the Pancreatic Remnant

Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database

BackgroundLittle is known about the effects of professional staffing on cancer surgical outcomes. The present study aimed to investigate the association between cancer surgical outcomes and physician/nurse staffing in relation to hospital volume.MethodsWe analyzed 131,394 patients undergoing lung lobectomy, esophagectomy, gastrectomy, colorectal surgery, hepatectomy or pancreatectomy for cancer between July and December, 2007–2008, using the Japanese Diagnosis Procedure Combination database linked to the Survey of Medical Institutions data. Physician-to-bed ratio (PBR) and nurse-to-bed ratio (NBR) were determined for each hospital. Hospital volume was categorized into low, medium and high for each of six cancer surgeries. Failure to rescue (FTR) was defined as a proportion of inhospital deaths among those with postoperative complications. Multi-level logistic regression analysis was performed to examine the association between physician/nurse staffing and FTR, adjusting for patient characteristics and hospital volume.ResultsOverall inhospital mortality was 1.8%, postoperative complication rate was 15.2%, and FTR rate was 11.9%. After adjustment for hospital volume, FTR rate in the group with high PBR (≥19.7 physicians per 100 beds) and high NBR (≥77.0 nurses per 100 beds) was significantly lower than that in the group with low PBR (<19.7) and low NBR (<77.0) (9.2% vs. 14.5%; odds ratio, 0.76; 95% confidence interval, 0.68–0.86; p < 0.001).ConclusionsWell-staffed hospitals confer a benefit for cancer surgical patients regarding reduced FTR, irrespective of hospital volume. These results suggest that consolidation of surgical centers linked with migration of medical professionals may improve the quality of cancer surgical management.

Low 18f-fluorodeoxyglucose uptake on positron emission tomography as a prognostic factor for stage I and II pancreatic cancer.

159 Background: Metabolic activity as defined by the uptake of 18F-fluorodeoxyglucose (FDG) on Positron Emission Tomography (PET) has proven beneficial as a prognostic marker for multiple malignancies; however, no study has examined the prognostic value of PET in stage I and II pancreatic cancer. We examined the value of PET FDG uptake in early pancreatic cancer. Methods: Using a comprehensive pancreatic adenocarcinoma database, we identified patients with early stage pancreatic cancer (I-II) who underwent pancreatectomy for cancer and had PET scan performed as part of their preoperative evaluation from 2004 to 2010. Patients were divided by the median primary tumor standard uptake value (SUVmax) into two groups: high and low FDG uptake. The primary outcomes were overall survival (OS) and disease free survival (DFS). Kaplan-Meier estimate was used for survival analysis. Pathologic data were compared using Fisher's exact and chi-square. Results: We identified 105 patients with resected stage I and II pancreatic cancer who had PET scans as part of their preoperative evaluation. 51 patients had low FDG uptake while 54 patients had high FDG uptake. The median age at diagnosis was 69 (24-89) years, 57% of the patients were male. 84 (81%) patients had PET avid tumors, while 20 (19%) patients did not. The median SUVmax was 5.1. High FDG uptake correlated with pathologic stage (p=0.012). Median follow-up was 12.3 (0-56) months. Patients with low FDG uptake had a significantly better median OS than patients with high FDG uptake (27 vs. 16 months; p=0.036). Recurrence occurred in 64 (60%) patients. Patients with low FDG uptake had significantly longer median DFS than patients with high FDG uptake (14 vs. 12 months; p=0.049). Conclusions: Low 18F-fluorodeoxyglucose uptake in PET scans for stage I and II pancreatic cancer correlates with improved overall survival and disease free survival. This observation supports the concept that glucose metabolic pathways are important in pancreatic cancer biology, and that PET scan activity can be used as a prognostic biomarker after pancreatectomy for pancreatic cancer.

Authors' reply: Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer (Br J Surg 2006; 93: 662 –673)

Authors' reply: Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer (<i>Br J Surg</i> 2006; 93: 662 –673)