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Journal of Investigative Surgery : the... Dec 2023Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For... (Review)
Review
Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For those that present with localized disease, a multidisciplinary approach is necessary to maximize survival and optimize outcomes. The quality and safety of surgery for pancreatic cancer have improved in recent years with increasing adoption of minimally invasive techniques and surgical adjuncts. Systemic chemotherapy has also evolved to impact survival. It is now increasingly being utilized in the neoadjuvant setting, often with concomitant radiation. Increased utilization of genomic testing in metastatic pancreatic cancer has led to better understanding of their biology, thereby allowing clinicians to consider potential targeted therapies. Similarly, targeted agents such as PARP inhibitors and immune checkpoint- inhibitors have emerged with promising results. In summary, pancreatic cancer remains a disease with poor long-term survival. However, recent developments have led to improved outcomes and have changed practice in the past decade. This review summarizes current practices in pancreatic cancer treatment and the milestones that brought us to where we are today, along with emerging therapies.
Topics: Humans; United States; Pancreatic Neoplasms; Combined Modality Therapy; Neoadjuvant Therapy; Antineoplastic Agents
PubMed: 36191926
DOI: 10.1080/08941939.2022.2129884 -
Gastroenterology Nov 2023Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary... (Comparative Study)
Comparative Study Randomized Controlled Trial
Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial).
BACKGROUND & AIMS
Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M).
METHODS
In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles.
RESULTS
From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted.
CONCLUSIONS
Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO.
CLINICALTRIALS
gov, Number: NCT03870386.
Topics: Humans; Male; Female; Cholangiopancreatography, Endoscopic Retrograde; Aged; Cholestasis; Middle Aged; Drainage; Stents; Endosonography; Treatment Outcome; Ultrasonography, Interventional; Choledochostomy; Metals; Aged, 80 and over
PubMed: 37549753
DOI: 10.1053/j.gastro.2023.07.024 -
Langenbeck's Archives of Surgery Aug 2023The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy.
METHOD
The MEDLINE, CENTRAL, EMBASE, Centre for Reviews and Dissemination, and clinical trial registries were systematically searched using the PRISMA framework. Studies of adults aged ≥ 18 year comparing laparoscopic and/or robotic versus open DP and/or PD that reported cost of operation or index admission, and cost-effectiveness outcomes were included. The risk of bias of non-randomised studies was assessed using the Newcastle-Ottawa Scale, while the Cochrane Risk of Bias 2 (RoB2) tool was used for randomised studies. Standardised mean differences (SMDs) with 95% confidence intervals (CI) were calculated for continuous variables.
RESULTS
Twenty-two studies (152,651 patients) were included in the systematic review and 15 studies in the meta-analysis (3 RCTs; 3 case-controlled; 9 retrospective studies). Of these, 1845 patients underwent MIS (1686 laparoscopic and 159 robotic) and 150,806 patients open surgery. The cost of surgical procedure (SMD 0.89; 95% CI 0.35 to 1.43; I = 91%; P = 0.001), equipment (SMD 3.73; 95% CI 1.55 to 5.91; I = 98%; P = 0.0008), and operating room occupation (SMD 1.17, 95% CI 0.11 to 2.24; I = 95%; P = 0.03) was higher with MIS. However, overall index hospitalisation costs trended lower with MIS (SMD - 0.13; 95% CI - 0.35 to 0.06; I = 80%; P = 0.17). There was significant heterogeneity among the studies.
CONCLUSION
Minimally invasive major pancreatic surgery entailed higher intraoperative but similar overall index hospitalisation costs.
Topics: Adult; Humans; Pancreatectomy; Retrospective Studies; Cost-Benefit Analysis; Pancreas; Pancreaticoduodenectomy; Minimally Invasive Surgical Procedures; Laparoscopy
PubMed: 37572127
DOI: 10.1007/s00423-023-03017-w -
World Journal of Gastrointestinal... Jun 2023The case of Crohn's disease involving the duodenum is rare, and its surgical management requires a thorough understanding.
BACKGROUND
The case of Crohn's disease involving the duodenum is rare, and its surgical management requires a thorough understanding.
AIM
To investigate the surgical management of duodenal Crohn's disease.
METHODS
We systematically reviewed patients diagnosed with duodenal Crohn's disease who underwent surgery in the Department of Geriatrics Surgery of the Second Xiangya Hospital of Central South University from January 1, 2004, to August 31, 2022. The general information, surgical procedures, prognosis, and other information of these patients were collected and summarized.
RESULTS
A total of 16 patients were diagnosed with duodenal Crohn's disease, where 6 cases had primary duodenal Crohn's disease, and 10 had secondary duodenal Crohn's disease. Among patients with primary disease, 5 underwent duodenal bypass and gastrojejunostomy, and 1 received pancreaticoduodenectomy. Among those with a secondary disease, 6 underwent closure of duodenal defect and colectomy, 3 received duodenal lesion exclusion and right hemicolectomy, and 1 underwent duodenal lesion exclusion and double-lumen ileostomy.
CONCLUSION
Crohn's disease involving the duodenum is a rare condition. Different surgical management should be applied for patients with Crohn's disease presenting with different clinical manifestations.
PubMed: 37405094
DOI: 10.4240/wjgs.v15.i6.1159 -
Journal of Investigative Surgery : the... Dec 2023Our objective is to compare the early outcomes associated with passive (gravity) drainage (PG) and active drainage (AD) after surgery. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Our objective is to compare the early outcomes associated with passive (gravity) drainage (PG) and active drainage (AD) after surgery.
METHODS
Studies published until April 28, 2022 were retrieved from the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science databases.
RESULTS
Nine studies with 14,169 patients were identified. Two groups had the same intra-abdominal infection rate (RR: 0.55; = 0.13); In subgroup analysis of pancreaticoduodenectomy, active drainage had no significant effect on postoperative pancreatic fistula (POPF) rate (RR: 1.21; = 0.26) and clinically relevant POPF (CR-POPF) (RR: 1.05; = 0.72); Active drainage was not associated with lower percutaneous drainage rate (RR: 1.00; = 0.96), incidence of sepsis (RR: 1.00; = 0.99) and overall morbidity (RR: 1.02; = 0.73). Both groups had the same POPF rate (RR: 1.20; = 0.18) and CR-POPF rate (RR: 1.20; = 0.18) after distal pancreatectomy. There was no difference between two groups on the day of drain removal after pancreaticoduodenectomy (Mean difference: -0.16; = 0.81) and liver surgery (Mean difference: 0.03; = 0.99).
CONCLUSIONS
Active drainage is not superior to passive drainage and both drainage methods can be considered.
Topics: Humans; Abdomen; Pancreas; Drainage; Pancreatectomy; Postoperative Complications; Pancreaticoduodenectomy
PubMed: 37733388
DOI: 10.1080/08941939.2023.2180115 -
Journal of Surgical Case Reports Jul 2023The incidence of bilateral adrenal hemorrhage (BAH) in the postoperative setting is rare, but potentially life threatening. A literature review of postoperative BAH...
The incidence of bilateral adrenal hemorrhage (BAH) in the postoperative setting is rare, but potentially life threatening. A literature review of postoperative BAH reveals that there is limited data on BAH following abdominal surgery. We present a case of BAH following pancreaticoduodenectomy, which has not been previously documented in the literature. A 70-year-old male patient with no previous history of adrenal disease underwent an uncomplicated pancreaticoduodenectomy and was discharged after a typical postoperative course. He was readmitted with abdominal pain and ileus on POD 8 and a computed tomography (CT) scan was initially unremarkable, but a repeat CT scan on POD 11 demonstrated BAH. He was found to have adrenal insufficiency and was successfully treated with steroids. Clinicians should be aware of the possibility of adrenal hemorrhage postoperatively as it can potentially be a fatal surgical complication. To enhance patient outcomes, early detection and appropriate treatment are essential.
PubMed: 37528912
DOI: 10.1093/jscr/rjad411 -
Annals of Surgery Apr 2024This study aimed to estimate whether the potential short-term advantages of laparoscopic pancreaticoduodenectomy (LPD) could allow patients to recover in a more timely... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
This study aimed to estimate whether the potential short-term advantages of laparoscopic pancreaticoduodenectomy (LPD) could allow patients to recover in a more timely manner and achieve better long-term survival than with open pancreaticoduodenectomy (OPD) in patients with pancreatic or periampullary tumors.
BACKGROUND
LPD has been demonstrated to be feasible and may have several potential advantages over OPD in terms of shorter hospital stay and accelerated recovery than OPD.
METHODS
This noninferiority, open-label, randomized clinical trial was conducted in 14 centers in China. The initial trial included 656 eligible patients with pancreatic or periampullary tumors enrolled from May 18, 2018, to December 19, 2019. The participants were randomized preoperatively in a 1:1 ratio to undergo either LPD (n=328) or OPD (n=328). The 3-year overall survival (OS), quality of life, which was assessed using the 3-level version of the European Quality of Life-5 Dimensions, depression, and other outcomes were evaluated.
RESULTS
Data from 656 patients [328 men (69.9%); mean (SD) age: 56.2 (10.7) years] who underwent pancreaticoduodenectomy were analyzed. For malignancies, the 3-year OS rates were 59.1% and 54.3% in the LPD and OPD groups, respectively ( P =0.33, hazard ratio: 1.16, 95% CI: 0.86-1.56). The 3-year OS rates for others were 81.3% and 85.6% in the LPD and OPD groups, respectively ( P =0.40, hazard ratio: 0.70, 95% CI: 0.30-1.63). No significant differences were observed in quality of life, depression and other outcomes between the 2 groups.
CONCLUSION
In patients with pancreatic or periampullary tumors, LPD performed by experienced surgeons resulted in a similar 3-year OS compared with OPD.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03138213.
Topics: Male; Humans; Middle Aged; Pancreaticoduodenectomy; Follow-Up Studies; Pancreatic Neoplasms; Quality of Life; Laparoscopy; Length of Stay; Retrospective Studies; Postoperative Complications
PubMed: 37965767
DOI: 10.1097/SLA.0000000000006149 -
Journal of Gastrointestinal Oncology Aug 2023Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical... (Review)
Review
BACKGROUND AND OBJECTIVE
Pancreatic adenocarcinoma remains a dismal disease and is expected to become an even greater burden in the near future. This review focuses on the different surgical aspects for pancreaticoduodenectomy (PD), distal and total pancreatectomy (TP), incorporating lessons from both the western and eastern visions in treating pancreatic cancer.
METHODS
We conducted an extensive literature review through PubMed, prioritizing papers published in the last 5 years, but older emblematic papers were also included. We included articles that explored the treatment of pancreatic adenocarcinoma, with focus on the surgical aspect and strategies to improve outcomes. References of selected articles were also reviewed to identify any missed studies. Only papers in English were included.
KEY CONTENT AND FINDINGS
As evidence continues to build, it is clear that both systemic and surgical therapies have a fundamental and complementary role. State of art surgical treatment encompasses complete mesopancreas excision for radical lymphadenectomy. Preoperative planning of dissection planes, extensive knowledge of vascular anatomic variations, oncological principles and expertise for vascular resections are mandatory to perform a more radical operation, in pursuit of improved outcomes.
CONCLUSIONS
Based on current data, patient selection remains key and a more radical surgical approach brings more accomplishing results bringing as to believe that more is better.
PubMed: 37720458
DOI: 10.21037/jgo-22-763