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HPB : the Official Journal of the... Oct 2022This study aims to describe the technique and the results of double-layer continuous suture hepaticojejunostomy (HJ) following pancreatoduodenectomy (PD) and total...
BACKGROUND
This study aims to describe the technique and the results of double-layer continuous suture hepaticojejunostomy (HJ) following pancreatoduodenectomy (PD) and total pancreatectomy (TP).
METHODS
A prospectively maintained database was analyzed retrospectively to identify incidence and severity of biliary leaks (BL) (ISGLS definition), as well as of HJ stenosis (HJS), cholangitis, and need for redo-HJ (in patients with a follow-up ≥3 years) in a consecutive series of 800 procedures (PD = 603; TP = 197). Predictors of biliary complications were also identified.
RESULTS
BLs occurred in 5 patients (0.6%), including 2 (0.3%) combined pancreatic and biliary leaks. Rates of HJS, cholangitis, and need for redo-HJ were 6.1%, 5.4%, and 2.0%, respectively. Incidence of BL was 0.6% in open procedures (4/587) and 0.4% in robotic operations (1/213). Incidence of late biliary complications was also equivalent in open and robotic procedures. Occurrence of BL was predicted by ASA IV status and duodenal cancer, HJS by any associated vascular procedure and hepatic duct size < 8 mm, cholangitis by any associated vascular procedure and normal bilirubin/hepatic enzymes, and redo HJ by history of cholecystectomy and neuroendocrine tumor/cancer.
DISCUSSION
Double layer continuous suture HJ is associated with low BL rates, and an acceptable incidence of late complications.
Topics: Humans; Pancreatectomy; Pancreaticoduodenectomy; Retrospective Studies; Biliary Tract Diseases; Cholangitis; Sutures; Bilirubin; Postoperative Complications
PubMed: 35654670
DOI: 10.1016/j.hpb.2022.05.005 -
Medicine Sep 2022Total pancreatectomy (TP) is performed for diseases of the entire pancreas. However, reluctance remains regarding TP because of the fear of high morbidity and mortality....
Total pancreatectomy (TP) is performed for diseases of the entire pancreas. However, reluctance remains regarding TP because of the fear of high morbidity and mortality. Our retrospective study aimed to evaluate the postoperative outcomes of TP performed at a high-volume single center and to identify the risk factors associated with major morbidities and mortality after TP. A total of 142 patients who underwent elective TP at Samsung Medical Center between 1995 and 2015 were included. TP was usually planned before surgery or decided during surgery [one-stage TP], and there were some completion TP cases that were performed to manage tumors that had formed in the remnant pancreas after a previous partial pancreatectomy [2-stage TP]. The differences between the 1-stage and 2-stage TP groups were analyzed. Chronological comparison was also conducted by dividing cases into 2 periods [the early and late period] based on the year TP was performed, which divided the total number of patients to almost half for each period. Among all TP patients, major morbidity occurred in 25 patients (17.6%), the rate of re-admission within 90-days was 20.4%, and there was no in-hospital and 30-days mortality. Between the 1-stage and 2-stage TP groups, most clinical, operative, and pathological characteristics, and postoperative outcomes did not differ significantly. Chronological comparison showed that, although the incidence of complications was higher, hospitalization was shorter due to advanced managements in the late period. The overall survival was improved in the late period compared to the early period, but it was not significant. A low preoperative protein level and N2 were identified as independent risk factors for major morbidity in multivariable analysis. The independent risk factors for poor overall survival were R1 resection, adenocarcinoma, and high estimated blood loss (EBL). TP is a safe and feasible procedure with satisfactory postoperative outcomes when performed at a high-volume center. More research and efforts are needed to significantly improve overall survival rate in the future.
Topics: Humans; Morbidity; Pancreatectomy; Pancreatic Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 36086699
DOI: 10.1097/MD.0000000000030390 -
JAMA Surgery Feb 2022Comparability of morbidity and mortality rates after total pancreatectomy (TP) reported by different surgical centers is limited. Procedure-specific differences, such as...
IMPORTANCE
Comparability of morbidity and mortality rates after total pancreatectomy (TP) reported by different surgical centers is limited. Procedure-specific differences, such as the extent of resection, including additional vascular or multivisceral resections, are rarely acknowledged when postoperative outcomes are reported.
OBJECTIVES
To evaluate postoperative outcomes after TP and categorize different types of TP based on the extent, complexity, and technical aspects of each procedure.
DESIGN, SETTING, AND PARTICIPANTS
This single-center study included a retrospective cohort of 1451 patients who had undergone TP between October 1, 2001, and December 31, 2020. Each patient was assigned to 1 of the following 4 categories that reflect increasing levels of procedure-related difficulty: standard TP (type 1), TP with venous resection (type 2), TP with multivisceral resection (type 3), and TP with arterial resection (type 4). Postoperative outcomes among the groups were compared.
MAIN OUTCOMES AND MEASURES
Categorization of different types of TP based on the procedure-related difficulty and differing postoperative outcomes.
RESULTS
Of the 1451 patients who had undergone TP and were included in the analysis, 840 were men (57.9%); median age was 64.9 (IQR, 56.7-71.7) years. A total of 676 patients (46.6%) were assigned to type 1, 296 patients (20.4%) to type 2, 314 patients (21.6%) to type 3, and 165 patients (11.4%) to type 4 TP. A gradual increase in surgical morbidity was noted by TP type (type 1: 255 [37.7%], type 2: 137 [46.3%], type 3: 178 [56.7%], and type 4: 98 [59.4%]; P < .001), as was noted for median length of hospital stay (type 1: 14 [IQR, 10-19] days, type 2: 16 [IQR, 12-23] days, type 3: 17 [IQR, 13-29] days, and type 4: 18 [IQR, 13-30] days; P < .001), and 90-day mortality (type 1: 23 [3.4%], type 2: 17 [5.7%], type 3: 29 [9.2%], and type 4: 20 [12.1%]; P < .001). In the multivariable analysis, type 3 (TP with multivisceral resection) and type 4 (TP with arterial resection) were independently associated with an increased 90-day mortality rate.
CONCLUSIONS AND RELEVANCE
The findings of this study suggest there are significant differences in postoperative outcomes when the extent, complexity, and technical aspects of the procedure are considered. Classifying TP into 4 different categories may allow for better postoperative risk stratification as well as more accurate comparisons in future studies.
Topics: Aged; Female; Germany; Humans; Male; Middle Aged; Outcome and Process Assessment, Health Care; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications; Risk Assessment
PubMed: 34787667
DOI: 10.1001/jamasurg.2021.5834 -
HPB : the Official Journal of the... Dec 2022Among patients with distant metastatic melanoma, the site of metastases is the most significant predictor of survival and visceral-nonpulmonary metastases hold the... (Review)
Review
BACKGROUND
Among patients with distant metastatic melanoma, the site of metastases is the most significant predictor of survival and visceral-nonpulmonary metastases hold the highest risk of poor outcomes. However, studies demonstrate that a significant percentage of patients may be considered candidates for resection with improved survival over nonsurgical therapeutic modalities. We aimed at analyzing the results of resection in patients with melanoma metastasis to the pancreas by assessing the available evidence.
METHODS
The PubMed/MEDLINE, WoS, and Embase electronic databases were systematically searched for articles reporting on the surgical treatment of pancreatic metastases from melanoma. Relevant data from included studies were assessed and analyzed. Overall survival was the primary endpoint of interest. Surgical details and oncological outcomes were also appraised.
RESULTS
A total of 109 patients treated surgically for pancreatic metastases were included across 72 articles and considered for data extraction. Overall, patients had a mean age of 51.8 years at diagnosis of pancreatic disease. The cumulative survival was 71%, 38%, and 26% at 1, 3 and 5 years after pancreatectomy, with an estimated median survival of 24 months. Incomplete resection and concomitant extrapancreatic metastasis were the only factors which significantly affected survival. Patients in whom the pancreas was the only metastatic site who received curative resection exhibited significantly longer survival, with a 1-year, 3-year, and 5-year survival rates of 76%, 43%, and 41%, respectively.
CONCLUSION
Within the limitations of a review of non-randomized reports, curative surgical resection confers a survival benefit in carefully selected patients with pancreatic dissemination of melanoma.
Topics: Humans; Middle Aged; Melanoma; Pancreas; Pancreatectomy; Pancreatic Neoplasms; Survival Rate
PubMed: 36167766
DOI: 10.1016/j.hpb.2022.08.012 -
Frontiers in Endocrinology 2023Total pancreatectomy (TP) has been increasingly performed in recent years. However, studies on diabetes management after TP during different postoperative periods are...
BACKGROUND
Total pancreatectomy (TP) has been increasingly performed in recent years. However, studies on diabetes management after TP during different postoperative periods are still limited.
OBJECTIVES
This study aimed to evaluate the glycemic control and insulin therapy of patients undergoing TP during the perioperative and long-term follow-up period.
METHODS
Ninety-three patients undergoing TP for diffuse pancreatic tumors from a single center in China were included. Based on preoperative glycemic status, patients were divided into three groups: nondiabetic group (NDG, n = 41), short-duration diabetic group (SDG, preoperative diabetes duration ≤12 months, n = 22), and long-duration diabetic group (LDG, preoperative diabetes duration >12 months, n = 30). Perioperative and long-term follow-up data, including the survival rate, glycemic control, and insulin regimens, were evaluated. Comparative analysis with complete insulin-deficient type 1 diabetes mellitus (T1DM) was conducted.
RESULTS
During hospitalization after TP, glucose values within the target (4.4-10.0 mmol/L) accounted for 43.3% of the total data, and 45.2% of the patients experienced hypoglycemic events. Patients received continuous intravenous insulin infusion during parenteral nutrition at a daily insulin dose of 1.20 ± 0.47 units/kg/day. In the long-term follow-up period, glycosylated hemoglobin A1 levels of 7.43 ± 0.76% in patients following TP, as well as time in range and coefficient of variation assessed by continuous glucose monitoring, were similar to those in patients with T1DM. However, patients after TP had lower daily insulin dose (0.49 ± 0.19 vs 0.65 ± 0.19 units/kg/day, < 0.001) and basal insulin percentage (39.4 ± 16.5 vs 43.9 ± 9.9%, = 0.035) than patients with T1DM, so did those using insulin pump therapy. Whether in the perioperative or long-term follow-up period, daily insulin dose was significantly higher in LDG patients than in NDG and SDG patients.
CONCLUSIONS
Insulin dose in patients undergoing TP varied according to different postoperative periods. During long-term follow-up, glycemic control and variability following TP were comparable to complete insulin-deficient T1DM but with fewer insulin needs. Preoperative glycemic status should be evaluated as it could guide insulin therapy after TP.
Topics: Humans; Diabetes Mellitus, Type 1; Pancreatectomy; Blood Glucose Self-Monitoring; Cohort Studies; Blood Glucose; Insulin; Glucose
PubMed: 36860372
DOI: 10.3389/fendo.2023.1097139 -
Surgical Endoscopy Jun 2023Robot-assisted distal pancreatectomy (RDP) has been suggested to hold some benefits over laparoscopic distal pancreatectomy (LDP) but consensus and data on specific... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Robot-assisted distal pancreatectomy (RDP) has been suggested to hold some benefits over laparoscopic distal pancreatectomy (LDP) but consensus and data on specific subgroups are lacking. This systematic review and meta-analysis reports the surgical and oncological outcome and costs between RDP and LDP including subgroups with intended spleen preservation and pancreatic ductal adenocarcinoma (PDAC).
METHODS
Studies comparing RDP and LDP were included from PubMed, Cochrane Central Register, and Embase (inception-July 2022). Primary outcomes were conversion and unplanned splenectomy. Secondary outcomes were R0 resection, lymph node yield, major morbidity, operative time, intraoperative blood loss, in-hospital mortality, operative costs, total costs and hospital stay.
RESULTS
Overall, 43 studies with 6757 patients were included, 2514 after RDP and 4243 after LDP. RDP was associated with a longer operative time (MD = 18.21, 95% CI 2.18-34.24), less blood loss (MD = 54.50, 95% CI - 84.49-24.50), and a lower conversion rate (OR = 0.44, 95% CI 0.36-0.55) compared to LDP. In spleen-preserving procedures, RDP was associated with more Kimura procedures (OR = 2.23, 95% CI 1.37-3.64) and a lower rate of unplanned splenectomies (OR = 0.32, 95% CI 0.24-0.42). In patients with PDAC, RDP was associated with a higher lymph node yield (MD = 3.95, 95% CI 1.67-6.23), but showed no difference in the rate of R0 resection (OR = 0.96, 95% CI 0.67-1.37). RDP was associated with higher total (MD = 3009.31, 95% CI 1776.37-4242.24) and operative costs (MD = 3390.40, 95% CI 1981.79-4799.00).
CONCLUSIONS
RDP was associated with a lower conversion rate, a higher spleen preservation rate and, in patients with PDAC, a higher lymph node yield and similar R0 resection rate, as compared to LDP. The potential benefits of RDP need to be weighed against the higher total and operative costs in future randomized trials.
Topics: Humans; Robotics; Robotic Surgical Procedures; Pancreatectomy; Treatment Outcome; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Laparoscopy; Operative Time; Length of Stay; Retrospective Studies
PubMed: 36781467
DOI: 10.1007/s00464-023-09894-y -
HPB : the Official Journal of the... Jan 2016Total pancreatectomy is infrequently performed for pancreatic cancer. Perceived operative mortality and questionable survival benefit deter many surgeons. Clinical... (Review)
Review
BACKGROUND
Total pancreatectomy is infrequently performed for pancreatic cancer. Perceived operative mortality and questionable survival benefit deter many surgeons. Clinical outcomes, described in single-center series, remain largely unknown.
METHODS
The National Cancer Database was queried for cases of pancreatic ductal adenocarcinoma undergoing total pancreatectomy (1998-2011). Univariate survival analyses were performed for 21 variables: demographic (8), tumor characteristics (5), surgery outcomes (6), and adjuvant therapy (2). The Log-rank test of differences in Kaplan-Meier survival curves was used for categorical variables. Variables with p < 0.05 were included in a multivariate analysis. Cox proportional hazards regression was used to analyze continuous variables and multivariate models.
RESULTS
2582 patients with staging and survival data made up the study population. 30-day mortality was 5.5%. Median overall survival was 15 months, with 1, 3, and 5-year survival rates of 60%, 22%, and 13%, respectively. Age, facility type, tumor size and grade, lymph node positivity, margin positivity, and adjuvant therapy significantly impacted survival in multivariate analysis.
CONCLUSION
Although total pancreatectomy is a reasonable option for selected patients with pancreatic ductal adenocarcinoma, survival of the entire group is limited. Operative mortality is improved from prior reports. Greater survival benefits were seen in younger patients with smaller, node negative tumors resected with negative margins in academic research centers.
Topics: Academic Medical Centers; Adult; Age Factors; Aged; Aged, 80 and over; Carcinoma, Pancreatic Ductal; Databases, Factual; Female; Humans; Kaplan-Meier Estimate; Lymphatic Metastasis; Male; Middle Aged; Multivariate Analysis; Neoplasm Staging; Pancreatectomy; Pancreatic Neoplasms; Patient Selection; Proportional Hazards Models; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Tumor Burden; United States
PubMed: 26776847
DOI: 10.1016/j.hpb.2015.07.009 -
The Journal of Medical Investigation :... 2023Several reports have shown the high mortality rate of pancreatic resection in patients with hemodialysis (HD), however, its long-term outcome remains unclear. In this... (Review)
Review
BACKGROUND
Several reports have shown the high mortality rate of pancreatic resection in patients with hemodialysis (HD), however, its long-term outcome remains unclear. In this study, we examined cases of pancreatic resection in patients with HD and conducted a literature review.
METHODS
Four patients with HD who underwent pancreatic resection from 2004 to 2019 were enrolled. To compare the clinicopathological variables of HD and non-HD patients, 161 non-HD patients who had undergone surgical resection for pancreatic cancer were enrolled.
RESULTS
Among four cases of pancreatic resection with HD, three cases were malignant diseases. All patients with HD had some co-morbidities (100% in HD group, 45.3% in the non-HD group) and postoperative complications (100% in the HD group, vs 46.6% in the non-HD group). Although one patient had severe postoperative complications and length of postoperative hospital stay was longer, the 30- and 90-day mortality rates were both 0% in patients with HD. However, three cases in the HD group (75%) died approximately 6 months after surgery, including one cancer-related death.
CONCLUSIONS
Pancreatic surgery in patients with HD should be carefully indicated, especially pancreaticoduodenectomy or total pancreatectomy, because of the poor prognosis induced by non-cancer-related causes of death. J. Med. Invest. 70 : 105-109, February, 2023.
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies
PubMed: 37164704
DOI: 10.2152/jmi.70.105 -
Journal of Hepato-biliary-pancreatic... Feb 2018Gastric venous congestion and bleeding in association with total pancreatectomy (TP) were evaluated. (Comparative Study)
Comparative Study
BACKGROUND
Gastric venous congestion and bleeding in association with total pancreatectomy (TP) were evaluated.
METHODS
Thirty-eight patients of TP were retrospectively analyzed. TP was classified as TP with distal gastrectomy (TPDG), pylorus-preserving TP (PPTP), subtotal stomach-preserving TP (SSPTP), and TP with segmental duodenectomy (TPSD).
RESULTS
Portal vein or superior mesenteric vein resection and reconstruction was performed in 24 patients (62.2%). Gastric bleeding occurred immediately after tumor resection in one of eight patients who underwent SSPTP, and urgent anastomosis between the right gastroepiploic and left ovarian vein stopped the bleeding. Another case of gastric bleeding was observed a few hours after TP in one of nine patients who underwent PPTP, and hemostasis was achieved after conservative therapy. Gastric bleeding was not observed in 16 patients who underwent TPDG and five who underwent TPSD. Some patients underwent preservation of gastric drainage veins (left gastric vein, right gastric vein, or right gastroepiploic vein). Neither patient with bleeding underwent preservation of a gastric drainage vein.
CONCLUSIONS
To preserve the subtotal or whole stomach when performing TP, one of the gastric drainage veins should undergo preservation or reconstruction, and anastomosis between the right gastroepiploic vein and left ovarian vein may be beneficial.
Topics: Adult; Aged; Cohort Studies; Disease-Free Survival; Female; Gastrectomy; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Hospitals, University; Humans; Hyperemia; Japan; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications; Reoperation; Retrospective Studies; Risk Assessment; Survival Analysis
PubMed: 29143477
DOI: 10.1002/jhbp.523 -
Digestive Surgery 2019Total dorsal pancreatectomy (TDP) is a conservative pancreatic resection that should be considered in cases of benign or low malignant tumors confined to the dorsal... (Review)
Review
BACKGROUND
Total dorsal pancreatectomy (TDP) is a conservative pancreatic resection that should be considered in cases of benign or low malignant tumors confined to the dorsal pancreas to preserve the viability of both digestive and biliary tracts, and to avoid the endocrine and metabolic consequences of total pancreatectomy. We report a new case of TDP and provide a literature review of this procedure.
METHODS
The case reported was a 35-year-old female patient with a solid pseudopapillary tumor. We resected the dorsal segment of the pancreas while preserving the common bile duct, gastroduodenal artery, and pancreaticoduodenal arcades, and the spleen and splenic vessels. The MEDLINE® and Embase® databases were searched for English language studies, case series, or case reports published through August 31, 2017.
RESULTS
The postoperative course was uneventful and patient was discharged on postoperative day 11. The patient was alive and in good condition at the 10-year follow-up. To date in English literature, there are only 3 reported cases of TDP, and all cases were patients with intraductal papillary mucinous neoplasia and pancreas divisum. There was no postoperative mortality, and 2 grade B pancreatic fistulas healed 1 month postoperatively.
CONCLUSIONS
TDP is a feasible and safe operation for benign or low grade malignant pancreatic tumors involving the dorsal pancreas, as an alternative to total pancreatectomy.
Topics: Adult; Female; Humans; Organ Sparing Treatments; Pancreatectomy; Pancreatic Neoplasms
PubMed: 30007967
DOI: 10.1159/000490198