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Cancers Apr 2021Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive... (Review)
Review
BACKGROUND
Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive surgeries such as distal pancreatectomy with celiac axis resection (DP-CAR) have become a therapeutical option.
METHODS
A meta-analysis of studies comparing DP-CAR and standard DP in patients with pancreatic adenocarcinoma was conducted. Moreover, a systematic review of studies analyzing oncological, postoperative and survival outcomes of DP-CAR was conducted.
RESULTS
Twenty-four articles were selected for the systematic review, whereas eleven were selected for the meta-analysis, for a total of 1077 patients. Survival outcomes between the two groups were similar in terms of 1 year overall survival (OS) (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.34 to 1.31, = 0.24). Patients who received DP-CAR were more likely to have T4 tumors (OR 28.45, 95% CI 10.46 to 77.37, < 0.00001) and positive margins (R+) (OR 2.28, 95% CI 1.24 to 4.17, = 0.008). Overall complications (OR, 1.72, 95% CI, 1.15 to 2.58, = 0.008) were more frequent in the DP-CAR group, whereas rates of pancreatic fistula (OR 1.16, 95% CI 0.81 to 1.65, = 0.41) were similar.
CONCLUSIONS
DP-CAR was not associated with higher mortality compared to standard DP; however, overall morbidity was higher. Celiac axis involvement should no longer be considered a strict contraindication to surgery in patients with locally advanced pancreatic adenocarcinoma. Considering the different baseline tumor characteristics, DP-CAR may need to be compared with palliative therapies instead of standard DP.
PubMed: 33921838
DOI: 10.3390/cancers13081967 -
Canadian Journal of Surgery. Journal... 2022Patients should be informed beforehand of the risk factors for exocrine pancreatic insufficiency (ExoPI) after pancreatic surgery; however, there are no clear identified... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients should be informed beforehand of the risk factors for exocrine pancreatic insufficiency (ExoPI) after pancreatic surgery; however, there are no clear identified risk factors for this condition. This study aimed to identify the preoperative, perioperative and postoperative risk factors for ExoPI after pancreatic surgery.
METHODS
We conducted a systematic search of PubMed, Scopus, SAGE, CINAHL Plus and Taylor & Francis from inception to Mar. 7, 2021, for full-text articles that included patients who had undergone pancreatic surgery. The primary outcome was the number of ExoPI events and any risk factors evaluated. We used the Newcastle-Ottawa Scale to assess study quality.
RESULTS
Twenty studies involving 4131 patients (2312 [52.3%] male, mean age 60.12 [standard deviation 14.07] yr) were included. Of the 4131 patients, 1651 (40.0%) had postoperative ExoPI. Among the 11 factors evaluated, the significant risk factors were preoperative main pancreatic duct (MPD) diameter greater than 3 mm (odds ratio [OR] 4.50, 95% confidence interval [CI] 1.06-19.05), pancreaticoduodenectomy (PD) as the surgical treatment procedure (OR 3.31, 95% CI 1.92-5.68), pancreaticogastrostomy (PG) as the anastomotic procedure (OR 3.13, 95% CI 1.83-5.35), hard pancreatic texture (OR 2.93, 95% CI 1.99-4.32) and adjuvant chemotherapy (OR 2.50, 95% CI 1.54-4.04). Gender, history of diabetes mellitus or endocrine pancreatic insufficiency (EndoPI), underlying diseases, de novo diabetes or EndoPI, pylorus-preserving PD and postoperative pancreatic fistula were not risk factors for ExoPI after pancreatic surgery.
CONCLUSION
Preoperative MPD diameter greater than 3 mm, PD, PG reconstruction, hard pancreatic texture and adjuvant chemotherapy were risk factors for the development of ExoPI after pancreatic surgery. The findings should provide useful information for patients to reduce postoperative dissatisfaction and improve quality of life.
Topics: Humans; Male; Middle Aged; Female; Quality of Life; Exocrine Pancreatic Insufficiency; Pancreaticoduodenectomy; Pancreatectomy; Pancreas; Postoperative Complications; Pancreatic Diseases
PubMed: 36384688
DOI: 10.1503/cjs.010621 -
ANZ Journal of Surgery Jun 2022Pancreatoduodenectomy (PD) remains the only curative-intent treatment option for patients with cancer affecting the head of the pancreas. It is high-risk and overall... (Review)
Review
BACKGROUND
Pancreatoduodenectomy (PD) remains the only curative-intent treatment option for patients with cancer affecting the head of the pancreas. It is high-risk and overall morbidity is around 40%. Due to the necessary resection and subsequent anastomoses required, multiple procedure-specific complications are possible. An in-depth understanding of the recent evidence on these will guide the consenting process and allow surgeons to evaluate their own performance. We aimed to consolidate the recent literature on preselected PD complications (postoperative pancreatic fistula (POPF), bile leak (BL), gastrojejunal leak, postpancreatectomy haemorrhage (PPH), cholangitis, and chyle leak (CL)).
METHODS
A search of the PubMed database was carried out on 1st July 2021. Articles from July 2011 through to July 2021 were included. The initial search returned 297 results. After screening, 226 articles were excluded. The remaining 71 were assessed for eligibility and a further 34 were excluded. 37 were included in the final synthesis (two meta-analyses and 35 single/multicentre studies).
RESULTS
Due to recently updated diagnostic criteria, differing definitions among authors and subclinical cases, true incidence rates are difficult to appreciate. The following were obtained: POPF (excluding biochemical leak): 10.0-25.9%, BL: 3.0-7.9%, gastrojejunal anastomotic leak: 0.4-1.2%, PPH: 7.3-13.6%, cholangitis: 0.05-21.1% and CL: 2.6-19.0%. Numerous risk factors, both modifiable and non-modifiable, were identified for each.
CONCLUSION
Most of the recent evidence on the studied complications comes from single institution studies of retrospective design. Robust case-control studies are required so predictive models can estimate the likelihood of specific complications in individual patients.
Topics: Cholangitis; Humans; Incidence; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 35088514
DOI: 10.1111/ans.17473 -
Frontiers in Oncology 2022To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological...
OBJECTIVE
To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis.
METHODS
PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.
RESULTS
Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA.
CONCLUSION
Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.
PubMed: 36578941
DOI: 10.3389/fonc.2022.1042493 -
Endoscopy International Open Apr 2022Treatment of necrotizing pancreatitis is changed over the past two decades with the availability of endoscopic, and minimally invasive surgical approaches. The aim of... (Review)
Review
Treatment of necrotizing pancreatitis is changed over the past two decades with the availability of endoscopic, and minimally invasive surgical approaches. The aim of this systematic review was to assess outcomes of endoscopic drainage, and different types of surgical drainage approaches in necrotizing pancreatitis. Medline, Embase, Scopus, and Web of Science were searched from 1998 to 2020 to assess outcomes in endoscopic drainage and various surgical drainage procedures. The assessed variables consisted of mortality, development of pancreatic or enteric fistula, new onset diabetes mellitus, and exocrine pancreatic insufficiency. One hundred seventy studies comprising 11,807 patients were included in the final analysis. The pooled mortality rate was 22 % (95 % confidence interval [CI]: 19%-26 %) in the open surgery (OS), 8 % (95 %CI:5 %-11 %) in minimally invasive surgery (MIS), 13 % (95 %CI: 9 %-18 %) in step-up approach, and 3 % (95 %CI:2 %-4 %) in the endoscopic drainage (ED). The pooled rate of fistula formation was 35 % (95 %CI:28 %-41 %) in the OS, 17 % (95 %CI: 12%-23 %) in MIS, 17 % (95 %CI: 9 %-27 %) in step-up approach, and 2 % (95 %CI: 0 %-4 %) in ED. There were 17 comparative studies comparing various surgical drainage methods with ED. The mortality rate was significantly lower in ED compared to OS (risk ratio [RR]: 30; 95 %CI: 0.20-0.45), and compared to MIS (RR: 0.40; 95 %CI: 0.26-0.6). Also, the rate of fistula formation was lower in ED compared to all other surgical drainage approaches. This systematic review demonstrated lower rate of fistula formation with ED compared to various surgical drainage methods. A lower rate of mortality with ED was also observed in observational studies. PROSPERO Identifier: CRD42020139354.
PubMed: 35433210
DOI: 10.1055/a-1783-9229 -
Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis.World Journal of Surgery Apr 2021Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population.
METHODS
We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020.
RESULTS
Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32-0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33-0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly.
CONCLUSION
MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.
Topics: Aged; Humans; Laparoscopy; Middle Aged; Operative Time; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies
PubMed: 33458781
DOI: 10.1007/s00268-020-05945-w -
HPB : the Official Journal of the... Sep 2020The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.
METHODS
Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.
RESULTS
Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).
DISCUSSION
Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
Topics: Anastomosis, Surgical; Humans; Ligaments; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 32631806
DOI: 10.1016/j.hpb.2020.05.003 -
International Journal of Surgery... Jul 2023Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD). However, its risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD). However, its risk factors are still unclear. This meta-analysis aimed to identify the potential risk factors of DGE among patients undergoing PD or PPPD.
MATERIALS AND METHODS
We searched PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, and ClinicalTrial.gov for studies that examined the clinical risk factors of DGE after PD or PPPD from inception through 31 July 2022. We pooled odds ratios (ORs) with 95% CIs using random-effects or fixed-effects models. We also performed heterogeneity, sensitivity, and publication bias analyses.
RESULTS
The study included a total of 31 research studies, which involved 9205 patients. The pooled analysis indicated that out of 16 nonsurgical-related risk factors, three risk factors were found to be associated with an increased incidence of DGE. These risk factors were older age (OR 1.37, P =0.005), preoperative biliary drainage (OR 1.34, P =0.006), and soft pancreas texture (OR 1.23, P =0.04). On the other hand, patients with dilated pancreatic duct (OR 0.59, P =0.005) had a decreased risk of DGE. Among 12 operation-related risk factors, more blood loss (OR 1.33, P =0.01), postoperative pancreatic fistula (POPF) (OR 2.09, P <0.001), intra-abdominal collection (OR 3.58, P =0.001), and intra-abdominal abscess (OR 3.06, P <0.0001) were more likely to cause DGE. However, our data also revealed 20 factors did not support stimulative factors influencing DGE.
CONCLUSION
Age, preoperative biliary drainage, pancreas texture, pancreatic duct size, blood loss, POPF, intra-abdominal collection, and intra-abdominal abscess are significantly associated with DGE. This meta-analysis may have utility in guiding clinical practice for improvements in screening patients with a high risk of DGE and selecting appropriate treatment measures.
Topics: Humans; Pancreaticoduodenectomy; Gastroparesis; Pylorus; Pancreatic Fistula; Risk Factors; Postoperative Complications; Abdominal Abscess; Gastric Emptying
PubMed: 37073540
DOI: 10.1097/JS9.0000000000000418 -
HPB : the Official Journal of the... Sep 2021Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative... (Meta-Analysis)
Meta-Analysis Review
The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies.
BACKGROUND
Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer.
METHODS
This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models.
RESULTS
Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity.
CONCLUSION
Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.
Topics: Chemoradiotherapy; Humans; Neoadjuvant Therapy; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications
PubMed: 34099372
DOI: 10.1016/j.hpb.2021.04.027 -
The Cochrane Database of Systematic... Jan 2022Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialised nations. For adenocarcinomas in the head of the gland and premalignant... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialised nations. For adenocarcinomas in the head of the gland and premalignant lesions, partial pancreaticoduodenectomy represents the standard treatment for resectable tumours. The gastro- or duodenojejunostomy after partial pancreaticoduodenectomy can be reestablished via either an antecolic or retrocolic route. The debate about the more favourable technique for bowel reconstruction is ongoing.
OBJECTIVES
To compare the effectiveness and safety of antecolic and retrocolic gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.
SEARCH METHODS
In this updated version, we conducted a systematic literature search up to 6 July 2021 to identify all randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library 2021, Issue 6, MEDLINE (1946 to 6 July 2021), and Embase (1974 to 6 July 2021). We applied no language restrictions. We handsearched reference lists of identified trials to identify further relevant trials, and searched the trial registries clinicaltrials.govand World Health Organization International Clinical Trials Registry Platform for ongoing trials.
SELECTION CRITERIA
We considered all RCTs comparing antecolic with retrocolic reconstruction of bowel continuity after partial pancreaticoduodenectomy for any given indication to be eligible.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the identified references and extracted data from the included trials. The same two review authors independently assessed risk of bias of included trials, according to standard Cochrane methodology. We used a random-effects model to pool the results of the individual trials in a meta-analysis. We used odds ratios (OR) to compare binary outcomes and mean differences (MD) for continuous outcomes.
MAIN RESULTS
Of a total of 287 citations identified by the systematic literature search, we included eight randomised controlled trials (reported in 11 publications), with a total of 818 participants. There was high risk of bias in all of the trials in regard to blinding of participants and/or outcome assessors and unclear risk for selective reporting in six of the trials. There was little or no difference in the frequency of delayed gastric emptying (OR 0.67; 95% confidence interval (CI) 0.41 to 1.09; eight trials, 818 participants, low-certainty evidence) with relevant heterogeneity between trials (I=40%). There was little or no difference in postoperative mortality (risk difference (RD) -0.00; 95% CI -0.02 to 0.01; eight trials, 818 participants, high-certainty evidence); postoperative pancreatic fistula (OR 1.01; 95% CI 0.73 to 1.40; eight trials, 818 participants, low-certainty evidence); postoperative haemorrhage (OR 0.87; 95% CI 0.47 to 1.59; six trials, 742 participants, low-certainty evidence); intra-abdominal abscess (OR 1.11; 95% CI 0.71 to 1.74; seven trials, 788 participants, low-certainty evidence); bile leakage (OR 0.82; 95% CI 0.35 to 1.91; seven trials, 606 participants, low-certainty evidence); reoperation rate (OR 0.68; 95% CI 0.34 to 1.36; five trials, 682 participants, low-certainty evidence); and length of hospital stay (MD -0.21; 95% CI -1.41 to 0.99; eight trials, 818 participants, low-certainty evidence). Only one trial reported quality of life, on a subgroup of 73 participants, also without a relevant difference between the two groups at any time point. The overall certainty of the evidence was low to moderate, due to some degree of heterogeneity, inconsistency and risk of bias in the included trials.
AUTHORS' CONCLUSIONS
There was low- to moderate-certainty evidence suggesting that antecolic reconstruction after partial pancreaticoduodenectomy results in little to no difference in morbidity, mortality, length of hospital stay, or quality of life. Due to heterogeneity in definitions of the endpoints between trials, and differences in postoperative management, future research should be based on clearly defined endpoints and standardised perioperative management, to potentially elucidate differences between these two procedures. Novel strategies should be evaluated for prophylaxis and treatment of common complications, such as delayed gastric emptying.
Topics: Humans; Length of Stay; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 35014692
DOI: 10.1002/14651858.CD011862.pub3