Pancreaticoduodenectomy For Cancer Research Articles

Superior Mesenteric Artery First Approach: A Safe Technique to Achieve Better Oncological Results after Pancreaticoduodenectomy for Cancer

Superior Mesenteric Artery First Approach: A Safe Technique to Achieve Better Oncological Results after Pancreaticoduodenectomy for Cancer

Effect of preoperative biliary stent on postoperative complications after pancreaticoduodenectomy for cancer: Neoadjuvant versus upfront treatment

BackgroundLimited data are available regarding the effect of preoperative biliary stent, during long-course neoadjuvant chemotherapy, on postoperative complications. The aim of the study is to analyze whether the association of neoadjuvant chemotherapy and biliary stent increases overall and infectious complications after pancreaticoduodenectomy. MethodsData for 538 consecutive pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy between 2015 and 2020 were retrospectively analyzed. Four groups of patients were identified: neoadjuvant chemotherapy + biliary stent (171 patients), neoadjuvant chemotherapy–no biliary stent (65 patients), upfront surgery + biliary stent (184 patients), and upfront surgery–no biliary stent (118 patients). Median neoadjuvant chemotherapy duration was 6 months. The main outcome of the study was the occurrence of postoperative infections. ResultsNo differences among the 4 groups were observed for pancreaticoduodenectomy-specific complications (ie, POPF, DGE, PPH). Infectious complications, in particular surgical site infections, were more frequent in neoadjuvant chemotherapy + biliary stent group (P = 0.001). At multivariate analysis, biliary stent was significantly associated with postoperative infectious complications in the overall cohort (odds ratio 1.996, confidence interval 95% 1.29–3.09, P = .002) and in neoadjuvant chemotherapy patients (odds ratio 5.974, 95% confidence interval 2.52–14.13, P < .001). Biliary stent significantly increased the comprehensive complication index by 9.5% (95% confidence interval 0.04–0.64, P = 0.024) in the overall cohort and 18.9% (95% confidence interval 0.22–1.23, P = .005) in the neoadjuvant chemotherapy group. The presence of multidrug-resistant microorganisms in intraoperative bile culture was not influenced by long-course neoadjuvant chemotherapy. ConclusionIn neoadjuvant chemotherapy patients, biliary stent increased the occurrence of postoperative infectious complications and surgical site infections, while the incidence of multidrug-resistant bacteria in intraoperative bile culture was similar between groups.

Neighborhood Deprivation, Hospital Quality, and Mortality After Cancer Surgery.

To evaluate if receipt of complex cancer surgery at high-quality hospitals is associated with a reduction in disparities between individuals living in the most and least deprived neighborhoods. The association between social risk factors and worse surgical outcomes for patients undergoing high-risk cancer operations is well documented. To what extent neighborhood socioeconomic deprivation as an isolated social risk factor known to be associated with worse outcomes can be mitigated by hospital quality is less known. Using 100% Medicare fee-for-service claims, we analyzed data on 212,962 Medicare beneficiaries more than age 65 undergoing liver resection, rectal resection, lung resection, esophagectomy, and pancreaticoduodenectomy for cancer between 2014 and 2018. Clinical risk-adjusted 30-day postoperative mortality rates were used to stratify hospitals into quintiles of quality. Beneficiaries were stratified into quintiles based on census tract Area Deprivation Index. The association of hospital quality and neighborhood deprivation with 30-day mortality was assessed using logistic regression. There were 212,962 patients in the cohort including 109,419 (51.4%) men with a mean (SD) age of 73.8 (5.9) years old. At low-quality hospitals, patients living in the most deprived areas had significantly higher risk-adjusted mortality than those from the least deprived areas for all procedures; esophagectomy: 22.3% versus 20.7%; P <0.003, liver resection 19.3% versus 16.4%; P <0.001, pancreatic resection 15.9% versus 12.9%; P <0.001, lung resection 8.3% versus 7.8%; P <0.001, rectal resection 8.8% versus 8.1%; P <0.001. Surgery at a high-quality hospitals was associated with no significant differences in mortality between individuals living in the most compared with least deprived neighborhoods for esophagectomy, rectal resection, liver resection, and pancreatectomy. For example, the adjusted odds of mortality between individuals living in the most deprived compared with least deprived neighborhoods following esophagectomy at low-quality hospitals (odds ratio=1.22, 95% CI: 1.14-1.31, P <0.001) was higher than at high-quality hospitals (odds ratio=0.98, 95% CI: 0.94-1.02, P =0.03). Receipt of complex cancer surgery at a high-quality hospital was associated with no significant differences in mortality between individuals living in the most deprived neighborhoods compared with least deprived. Initiatives to increase access referrals to high-quality hospitals for patients from high deprivation levels may improve outcomes and contribute to mitigating disparities.

Effects of body mass index and serum albumin on overall survival in patients with cancer undergoing pancreaticoduodenectomy: a single-center retrospective cohort study

ObjectivesWe aimed to explore whether body mass index (BMI) and albumin were associated with overall survival (OS) in individuals who underwent pancreaticoduodenectomy (PD) for cancer.MethodsThree-hundred twenty-nine consecutive patients who underwent PD for cancer were enrolled from January 2020 to December 2020. All clinicopathological information was extracted based on medical records. The survival follow-ups were regularly performed and ended on June 30, 2021. The Kaplan-Meier survival analysis and univariate and multivariate Cox proportional-hazards models were used to assess the association of BMI and albumin with OS.ResultsOf the 329 patients, 186 (56.5%) were male, and median age at admission was 65.0 (56.0–71.0) years. There were 258 patients (78.4%) with BMI < 25.0 kg/m2 and 89 patients (27.05%) with albumin < 35.0 g/L respectively. In overall cohort, BMI < 25.0 kg/m2 was associated with OS (adjusted HR = 3.516, 95% CI = 1.076–11.492, P = 0.037). In contrast, albumin < 35.0 g/L did not affect OS. Subgroup analysis showed, in patients with pancreas lesion, BMI < 25.0 kg/m2 had a higher risk for OS compared to BMI ≥ 25.0 kg/m2 (adjusted HR = 3.209, 95% CI = 0.985–10.451, P = 0.048), while albumin < 35.0 g/L was not linked to OS. In patients with lesion in ampulla of Vater, duodenum, or common bile duct, there was no significant association of BMI and albumin with OS.ConclusionsBMI, rather than serum albumin, was associated with OS in patients who underwent PD for cancer.

ASO Author Reflections: The Impact of CT-assessed Liver Steatosis on Postoperative Complications after Pancreaticoduodenectomy for Cancer.

ASO Author Reflections: The Impact of CT-assessed Liver Steatosis on Postoperative Complications after Pancreaticoduodenectomy for Cancer.

'You know where we are if you need us.' The role of primary care in supporting patients following pancreaticoduodenectomy for cancer: a qualitative study.

BackgroundTen per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. It is known that these patients have unmet psychological support needs, and GPs are key in enabling effective coordination of care for people living with life-shortening conditions.AimTo explore patients’ perspectives on the role of primary care in their management, and their sources of support.Design & settingInductive qualitative study of patients who had undergone pancreaticoduodenectomy between 6 months and 6 years previously for pancreatic or distal biliary duct cancers. Participants were recruited by clinical nurse specialists (CNSs) from a single NHS trust in Northwest England.MethodSemi-structured interviews, either face-to-face or via video link, were conducted with 20 participants. Interviews were audio-recorded, transcribed, and anonymised. Thematic analysis utilised principles of constant comparison.ResultsParticipants described immense treatment burden and uncertainty around the role of the GP in their ongoing care. They recognised that GPs may have little experience of patients who have undergone pancreaticoduodenectomy, but felt that GPs can play a vital role in offering support. Participants wished for emotional support postoperatively, and valued support networks including family and friends. However, they found expressing their deepest fears difficult. Participants felt they would value greater recognition by primary care of both physical and psychological sequelae of major pancreatic surgery, and the impact on their families.ConclusionPatients may feel themselves to be a ‘burden’ to both healthcare professionals and their own support networks following pancreaticoduodenectomy. Primary care is in a key position to proactively offer psychological support.

‘It’s always in the back of my mind’: understanding the psychological impact of recovery following pancreaticoduodenectomy for cancer: a qualitative study

ObjectivesTen per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs impact negatively on quality of life. This...

Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer.

Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy. The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ2 test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis. Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity. Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.

Whipple's pancreaticoduodenectomy for cancer of the head of the pancreas in a patient with amyotrophic lateral sclerosis: perioperative challenges.

The association of amyotrophic lateral sclerosis and pancreatic cancer is rare. Amyotrophic lateral sclerosis is a neurodegenerative disease characterised by pure motor symptoms in the form of progressive muscle weakness and wasting, and can involve the bulbar and respiratory muscles, leading to significant morbidity. Successful surgery for patients with amyotrophic lateral sclerosis for pancreatic cancer has rarely been reported. Surgery in such patients is a dual-edged sword and is decided based on risk-benefit ratio. Patients are at high risk for general anaesthesia because of muscular weakness, increased sensitivity to muscle relaxants and certain anaesthetic drugs. There is a high chance of prolonged postoperative ventilatory support, aspiration pneumonia and pulmonary complications. We report a patient with cancer of the head of the pancreas who underwent successful elective pancreaticoduodenectomy.

Surgical treatment of gastric venous congestion in association with extended resection of pancreas: a case report

BackgroundTotal pancreatectomy is performed for chronic pancreatitis, tumors involving the entire pancreas or remnant pancreas after pancreatectomy. Gastric venous congestion and bleeding may be associated with total pancreatectomy. We report the case of a patient who underwent left gastric vein to splenic vein bypass to relieve gastric venous congestion during total pancreatectomy for remnant pancreatic cancer.Case presentationA 60-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the pancreatic head. A follow-up computed tomography revealed a low-density tumor of the remnant pancreas. The pathological diagnosis was adenocarcinoma on endoscopic ultrasound-fine needle aspiration. Total resection of the remnant pancreas was performed for the tumor 3 years after the initial surgery. We ligated the splenic vein at the point of distal side of the left gastric vein confluent. Immediately, the vein congestion around the stomach was confirmed. We found the stenosis of the confluent between the left gastric vein and splenic vein. We subsequently anastomosed the left gastric vein and splenic vein, following which the gastric venous congestion was relieved.ConclusionIn cases wherein all the drainage veins from the stomach are removed, an anastomosis between the left gastric vein and splenic vein can be effectively used to prevent gastric venous congestion and bleeding after total pancreatectomy.

Main Pancreatic Duct to Parenchymal Thickness Ratio at Preoperative Imaging is Associated with Overall Survival in Upfront Resected Pancreatic Cancer.

Pancreatic cancer induces parenchymal atrophy and duct dilation. The aim of this study was to evaluate whether these radiologic modifications are associated with outcomes. Upfront pancreaticoduodenectomy patients with available preoperative contrast enhanced CT scan imaging were retrospectively analyzed. Thickness of the pancreas, size of the main pancreatic duct (MPD), and distance of the tumor from the ampulla were assessed. A training cohort was selected, including short- (3-12months following surgery) and long-term (≥ 36months) survivors. Identified survival determinants were validated in the overall cohort. Two-hundred-sixteen patients were analyzed. In the training cohort (N = 118), 68 patients (57.6%) were in the short-term and 50 (42.4%) in the long-term survival group. The short-term survival group had significantly higher CA 19-9 levels (p = 0.027), larger tumors (32.6 ± 12.1mm vs. 26.5 ± 11.6mm, p = 0.007), poorer differentiation (p = 0.003), higher rate of R < 1mm resections (54% vs. 32%, p = 0.008), and reduced receipt of adjuvant chemotherapy (p = 0.020). The MPD-to-pancreatic thickness ratio was significantly lower in the short-term survivors (3.6 ± 6.2 vs. 8.2 ± 12.0, p = 0.016). In the entire cohort, an MPD-to-pancreatic thickness ratio ≥ 3.5 was associated with improved OS [median 33.0months IQR (19.7-48.1) versus 17months IQR (14.8-19.2), p = 0.004], and confirmed by a Cox-proportional hazards model independently associated with OS (HR = 0.58; p = 0.009), together with tumor size (HR = 1.02; p =0.012), R1/R2 status (HR = 1.53; p = 0.029), and receipt of adjuvant treatment (HR = 0.61; p = 0.021). High MPD-to-pancreatic thickness ratio was associated with improved long-term survival in pancreaticoduodenectomy for cancer. Whether these features are related to tumor chronicity, indolent biology, or local growth over metastasis remains to be determined.

Assessment of hospital characteristics associated with improved mortality following complex upper gastrointestinal cancer surgery in Queensland

High hospital-volume and service capability are associated with improved mortality following complex cancer surgery. Using a population-based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high- and low-volume hospitals stratified by service capability. Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into 'high-volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; 'low-volume (<6) with high service capability' and 'low-volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30- and 90-day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time-period. For oesophagectomy, adjusted 90-day mortality was higher in low-volume compared with high-volume hospitals, regardless of service capability (low-volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74-8.57; low-volume, low service: IRR 3.40, 95% CI 1.16-10.00). For pancreaticoduodenectomy, mortality was higher in low-volume compared with high-volume centres regardless of service capability: 30-day mortality (low-volume, high service: IRR 2.32, 95% CI 1.07-5.03; low-volume, low service: IRR 3.92, 95% CI 1.45-10.61); 90-day mortality (low-volume, high service: IRR 2.36, 95% CI 1.29-4.30; low-volume, low service: IRR 3.32, 95% CI 1.64-6.71). High hospital resection volumes are associated with lower post-operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high-volume centres.

Drain fluid amylase levels after pancreaticoduodenectomy for cancer: correlation with outcomes and complications and evolution of a uniform grading system

Drain fluid amylase levels after pancreaticoduodenectomy for cancer: correlation with outcomes and complications and evolution of a uniform grading system

Drain amylase levels following pancreaticoduodenectomy for cancer; correlation with outcomes and proposal for a uniform grading system

Drain amylase levels following pancreaticoduodenectomy for cancer; correlation with outcomes and proposal for a uniform grading system

Impact of Sarcopenic Obesity on Failure to Rescue from Major Complications Following Pancreaticoduodenectomy for Cancer: Results from a Multicenter Study.

Failure to rescue (FTR) is a quality-of-care indicator in pancreatic surgery, but may also identify patients who may not tolerate major postoperative complications despite being treated with best available care. Previous studies found that high visceral adipose tissue-to-skeletal muscle ratio is associated with poor outcomes following pancreaticoduodenectomy (PD). The aim of the study is to assess the impact of sarcopenic obesity on occurrence of FTR from major complications in cancer patients undergoing PD. Prospectively collected data from three high-volume hospitals were reviewed. Total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed at preoperative staging computed tomography scan. Sarcopenic obesity was defined as high VFA/TAMA ratio. FTR was defined as postoperative mortality following major complication. 120 patients with major complications were included. FTR occurred in 23 (19.2%) patients. The "seminal" complications leading to FTR were pancreatic or biliary fistula-related sepsis (n=14), postoperative pancreatic fistula (POPF)-related hemorrhage (n=5), and duodenojejunal anastomosis leak-related sepsis (n=1). On univariate analysis, older age [odds ratio (OR) 3.5, p=0.034], American Society of Anesthesiologists (ASA) score 3+(OR 4.2, p=0.005), cardiovascular disease (OR 3.3, p=0.013), low serum albumin (OR 2.6, p=0.042), sarcopenic obesity (OR 4.2, p=0.009), POPF (OR 3.1, p=0.027), and cardiorespiratory complications (OR 3.7, p=0.011) were significantly associated with FTR. On multivariate analysis, sarcopenic obesity [OR 5.7, 95% confidence interval (CI) 1.6-20.7, p=0.008], ASA score 3+(OR 4.1, 95% CI 1.2-14.3, p=0.025), and pancreatic fistula (OR 3.2, 95% CI 1.0-10.2, p=0.045) were independently associated with FTR. Sarcopenic obesity, low preoperative physical status, and occurrence of pancreatic fistula are associated with significantly higher risk of FTR from major complications after PD.

SMA first approach Pancreaticoduodenectomy for cancer – should it be standard approach?

Background: pancreaticoduodenectomy (PD) has become the standard treatment for cancer of head of pancrease and periampullary malignancies. Recently superior mesenteric artery (SMA) first approach has shown to have several advantages over the conventional superior mesenteric vein (SMV) first approach. We present our initial experience with SMA first approach for PD.Methods: Thirteen patients undergoing SMA first PD during year 2014-2015 (1 year) were prospectively studied. A posterior approach with “hanging maneuver” was used to identify SMA first and the resectibility was confirmed. Inferior pancreaticoduodenal artery (IPDA) was ligated before the division of pancreatic neck. Duct to mucosa pancreaticojejunostomy followed by hepaticojejunostomy and gastrojejunostomy was performed.Results: patients with mean age of 53 years presented with abdominal pain and jaundice (100%). Tumors were of periampullary region in 10 cases and of head of pancrease in three cases. Two patients required partial SMV wall resection with tangential repair. Mean operating time, blood loss and postoperative stay was 304 minutes, 380 ml and 14 days, respectively. Replaced/ aberrant right hepatic artery from SMA was observed in 38% cases. Mean number of dissected nodes was 16. R0 resection was achieved in 100% cases. There was one postoperative mortality (7.7%) and minor complications were noted in 46% cases.Conclusion: SMA first PD helps to properly identify and control anomalous or accessory right hepatic artery arising from SMA, minimizes intraoperative bleeding due to proper control.

Do post-operative complications really affect oncological results after pancreatico-duodenectomy for cancer?

Do post-operative complications really affect oncological results after pancreatico-duodenectomy for cancer?

Su1824 Impact of Preoperative Biliary Drainage on Short-and Long-Term Outcome After Pancreaticoduodenectomy for Cancer of the Head of Pancreas

Su1824 Impact of Preoperative Biliary Drainage on Short-and Long-Term Outcome After Pancreaticoduodenectomy for Cancer of the Head of Pancreas

Benefit from synchronous portal-superior mesenteric vein resection during pancreaticoduodenectomy for cancer: A meta-analysis

Pancreaticoduodenectomy combined with portal-superior mesenteric vein synchronous resection for cancer remains a hot debate topic. The present study used meta-analytical technique to provide update information and an evidence-based evaluation on both the perioperative benefit and long-term survival. A meta-analysis was performed to evaluate studies comparing venous resection (VR) versus without venous resection (WVR) groups. 22 retrospective studies including 2890 patients were eligible for an analysis of perioperative morbidity, mortality, and long-term survival. Furthermore, subgroup analysis was made according to histopathology and resection margin status respectively for the purpose of survival assessment. There was no difference in perioperative morbidity, mortality and 1-year, 3-year survival between two groups, but showed differences in median tumor size (P < 0.001), R0 resection rate (P < 0.001), lymph node metastasis (P = 0.03), pancreatic fistula (P = 0.01), and 5-year survival (P = 0.03). In subgroup analysis, patients in venous resection group received R0 resection had a significantly better survival comparing with who received R1 resection both at 2-year (P < 0.001) and 5-year (P = 0.00002). In histopathology subgroup, patients in venous resection groups who had true tumor infiltration had a significantly bad survival comparing with whom only with inflammation pathology. Pancreaticoduodenectomy combined with venous resection can achieve equal perioperative morbidity and mortality as standard resection. However, in order to obtain an optimal survival outcome, surgeons should make an R0 resection as far as possible, especially in cases need synchronous venous resection.

Cardiopulmonary Exercise Testing for Preoperative Risk Assessment before Pancreaticoduodenectomy for Cancer

Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy. In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival. A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ([Formula: see text] O 2 MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ([Formula: see text] E/[Formula: see text] CO 2) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95% confidence interval [CI] 0.63-1.00, p=0.020); a threshold of 41 was 75% sensitive and 95% specific (positive predictive value 50%, negative predictive value 98%). Above this threshold, raised [Formula: see text] E/[Formula: see text] CO 2 predicted poor long-term survival (hazard ratio 2.05, 95% CI 1.09-3.86, p=0.026). CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived [Formula: see text] E/[Formula: see text] CO 2 predicts early postoperative death and poor long-term survival.