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Digestive Surgery 2016Intraductal papillary mucinous neoplasms (IPMN) are cystic precursors to pancreatic cancer believed to arise within a widespread neoplastic field defect. The tendency... (Review)
Review
Intraductal papillary mucinous neoplasms (IPMN) are cystic precursors to pancreatic cancer believed to arise within a widespread neoplastic field defect. The tendency for some patients to present with multifocal disease and/or develop additional lesions over time argues in favor of a field defect and complicates surgical management decisions. Surgery usually consists of partial pancreatic resection, which leaves behind a pancreatic remnant at risk for recurrent disease and progression to cancer. As an alternative, total pancreatectomy (TP) provides the most complete oncologic resection, but postoperative morbidity and quality of life (QoL) issues have generally limited its use to only the highest risk patients. Significant progress has been made in the management of the post-TP apancreatic state and studies now show less morbidity with acceptable QoL comparable to type 1 diabetic and post-pancreaticoduodenectomy patients. These improvements do not yet justify the routine use of TP, but they have opened the door for expansion to additional subsets of non-invasive IPMN. Here, we have identified several groups of patients that we believe would benefit from TP over partial resection based on the most current literature.
Topics: Humans; Margins of Excision; Neoplasm Recurrence, Local; Neoplasm, Residual; Neoplasms, Cystic, Mucinous, and Serous; Neoplasms, Multiple Primary; Pancreatectomy; Pancreatic Ducts; Pancreatic Neoplasms; Patient Selection; Practice Guidelines as Topic; Quality of Life
PubMed: 27215900
DOI: 10.1159/000445019 -
BMC Surgery Oct 2019The outcomes in patients with pancreatic or ampulla tumors remain unsatisfactory, especially with invasion into the hepatic artery (HA) or the superior mesenteric artery...
BACKGROUND
The outcomes in patients with pancreatic or ampulla tumors remain unsatisfactory, especially with invasion into the hepatic artery (HA) or the superior mesenteric artery (SMA). In this setting, pancreatectomy combined with arterial resection and reconstruction may offer the possibility of an en-block resection with negative margins and acceptable morbidity and mortality.
METHODS
A six year retrospective review of pancreatectomies performed at our institution, included 21 patients that underwent a pancreatectomy combined with arterial resection and reconstruction. Arterial reconstruction was performed under an operating microscope. The types of arterial reconstruction included direct anastomosis, arterial transposition, and arterial bypass with a vascular graft.
RESULTS
The surgical procedures consisted of 19 pancreaticoduodenectomies and 2 total pancreatectomies. The tumors were located at the pancreatic head (n = 10), whole pancreas (n = 2), distal common bile duct (n = 5), ampulla (n = 2) and retroperitoneum with pancreatic head involvement (n = 2). All operations achieved R0 resection successfully, with no intraoperative complication. Eighteen patients recovered without complications while three patients died from intra-abdominal hemorrhage due to a pancreatic fistula, though notably the bleeding was not at the arterial anastomosis site. All reconstructed arteries showed adequate patency at follow-up. The median postoperative survival was 11.6 months in all the 11 patients with pancreatic adenocarcinoma.
CONCLUSION
Pancreatectomy combined with arterial resection and reconstruction is a feasible treatment option. The microsurgical technique is critically important to achieving a successful and patent arterial anastomosis.
Topics: Adenocarcinoma; Adult; Aged; Ampulla of Vater; Female; Hepatic Artery; Humans; Male; Mesenteric Artery, Superior; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Plastic Surgery Procedures; Retrospective Studies; Vascular Surgical Procedures; Young Adult
PubMed: 31601220
DOI: 10.1186/s12893-019-0560-2 -
HPB : the Official Journal of the... Nov 2022Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years...
BACKGROUND
Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years.
METHODS
Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively.
RESULTS
Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months.
CONCLUSION
This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.
Topics: Humans; Pancreatectomy; Transplantation, Autologous; Islets of Langerhans Transplantation; Quality of Life; Treatment Outcome; Pancreatitis, Chronic; Islets of Langerhans
PubMed: 35927127
DOI: 10.1016/j.hpb.2022.07.001 -
Perioperative Nutritional Aspects in Total Pancreatectomy: A Comprehensive Review of the Literature.Nutrients May 2021Total pancreatectomy (TP) is a highly invasive procedure often performed in patients affected by anorexia, malabsorption, cachexia, and malnutrition, which are risk...
Total pancreatectomy (TP) is a highly invasive procedure often performed in patients affected by anorexia, malabsorption, cachexia, and malnutrition, which are risk factors for bad surgical outcome and even may cause enhanced toxicity to chemo-radiotherapy. The role of nutritional therapies and the association between nutritional aspects and the outcome of patients who have undergone TP is described in some studies. The aim of this comprehensive review is to summarize the available recent evidence about the influence of nutritional factors in TP. Preoperative nutritional and metabolic assessment, but also intra-operative and post-operative nutritional therapies and their consequences, are analyzed in order to identify the aspects that can influence the outcome of patients undergoing TP. The results of this review show that preoperative nutritional status, sarcopenia, BMI and serum albumin are prognostic factors both in TP for pancreatic cancer to support chemotherapy, prevent recurrence and prolong survival, and in TP with islet auto-transplantation for chronic pancreatitis to improve postoperative glycemic control and obtain better outcomes. When it is possible, enteral nutrition is always preferable to parenteral nutrition, with the aim to prevent or reduce cachexia. Nowadays, the nutritional consequences of TP, including diabetes control, are improved and become more manageable.
Topics: Body Mass Index; Female; Humans; Islets of Langerhans Transplantation; Male; Nutrition Therapy; Nutritional Status; Pancreatectomy; Pancreatic Neoplasms; Pancreatitis, Chronic; Postoperative Complications; Prognosis; Risk Factors; Sarcopenia; Serum Albumin
PubMed: 34067286
DOI: 10.3390/nu13061765 -
The British Journal of Surgery May 2024Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of...
BACKGROUND
Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified.
METHODS
A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).
RESULTS
In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers.
CONCLUSION
Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.
Topics: Humans; Benchmarking; Quality Indicators, Health Care; Netherlands; Pancreatectomy; Male; Pancreaticoduodenectomy; Hepatectomy; Female; Middle Aged; Aged; Hospital Mortality
PubMed: 38747683
DOI: 10.1093/bjs/znae119 -
United European Gastroenterology Journal Oct 2020Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal...
Prophylactic total pancreatectomy in individuals at high risk of pancreatic ductal adenocarcinoma (PROPAN): systematic review and shared decision-making programme using decision tables.
BACKGROUND
Individuals with a very high lifetime risk of developing pancreatic ductal adenocarcinoma; for example, hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm, may wish to discuss prophylactic total pancreatectomy but strategies to do so are lacking.
OBJECTIVE
To develop a shared decision-making programme for prophylactic total pancreatectomy using decision tables.
METHODS
Focus group meetings with patients were used to identify relevant questions. Systematic reviews were performed to answer these questions.
RESULTS
The first tables included hereditary pancreatitis and main-duct or mixed-type intraductal papillary mucinous neoplasm. No studies focused on prophylactic total pancreatectomy in these groups. In 52 studies (3570 patients), major morbidity after total pancreatectomy was 25% and 30-day mortality was 6%. After minimally invasive total pancreatectomy (seven studies, 35 patients) this was, respectively, 13% and 0%. Exocrine insufficiency-related symptoms occurred in 33%. Quality of life after total pancreatectomy was slightly lower compared with the general population.
CONCLUSION
The decision tables can be helpful for discussing prophylactic total pancreatectomy with individuals at high risk of pancreatic ductal adenocarcinoma.
Topics: Carcinoma, Pancreatic Ductal; Decision Making, Shared; Decision Support Techniques; Disease Progression; Exocrine Pancreatic Insufficiency; Humans; Pancreatectomy; Pancreatic Ducts; Pancreatic Neoplasms; Pancreatitis, Chronic; Postoperative Complications; Prophylactic Surgical Procedures; Quality of Life; Risk Assessment; Treatment Outcome
PubMed: 32703081
DOI: 10.1177/2050640620945534 -
HPB : the Official Journal of the... Jul 2022While pancreatectomy with portomesenteric venous resection and reconstruction is commonly performed for locally advanced pancreatic adenocarcinoma, little is known...
BACKGROUND
While pancreatectomy with portomesenteric venous resection and reconstruction is commonly performed for locally advanced pancreatic adenocarcinoma, little is known regarding outcomes for pancreatic neuroendocrine neoplasms (panNENs).
METHODS
Patients who underwent non-parenchyma-sparing pancreatectomy for panNENs at Mayo Clinic from 2000 to 2020 were retrospectively reviewed. Propensity score matching was performed and patient characteristics and outcomes compared.
RESULTS
Of 867 eligible patients, 41 (4.7%) required vascular resection, including 38 patients who underwent portomesenteric venous resection only. Of these, 23 underwent pancreaticoduodenectomy or total pancreatectomy and 15 distal pancreatectomy. Patients who required portomesenteric venous resection had larger tumors, higher tumor grade, and higher disease stage. After propensity score matching to patients undergoing standard resection, the portomesenteric venous resection group had longer operative times, greater blood loss, and higher transfusion rates. While portomesenteric venous thrombosis was more common after venous resection, major complication rates and perioperative mortality were similar between the two groups, as were 5-year overall and progression-free survival.
CONCLUSION
For patients with locally advanced panNENs, pancreatectomy with portomesenteric venous resection and reconstruction can be performed in selected patients at high-volume centers with acceptable perioperative morbidity and short- and long-term survival.
Topics: Adenocarcinoma; Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Retrospective Studies
PubMed: 35078716
DOI: 10.1016/j.hpb.2021.12.016 -
Journal of Visceral Surgery Sep 2017Operative injury to the hepatic artery is a serious complication of pancreaticoduodenectomy and guidelines to manage this complication are lacking. (Review)
Review
BACKGROUND
Operative injury to the hepatic artery is a serious complication of pancreaticoduodenectomy and guidelines to manage this complication are lacking.
METHODS
A systematic search performed in PubMed database identified eleven studies overall including 20 patients having sustained injury to the hepatic artery during pancreaticoduodenectomy (n=18) or total pancreatectomy (n=2). One further unpublished personal observation following pancreaticoduodenectomy was also included.
RESULTS
Sixteen of 21 patients (76%) experienced serious complications including liver necrosis/abscess (n=14), acute liver failure (n=3), and biliary anastomotic dehiscence (n=6). Eleven patients (52%) were reoperated and 5 patients died (24%). Arterial injury was recognized and repaired immediately in five patients, four recovering uneventfully and one dying from acute liver failure (20%). In contrast delayed or conservative treatment in 16 patients was associated with serious early morbidity in 15 patients (94%), leading to death in 4 patients and late biliary complications in four others.
CONCLUSIONS
Accidental interruption of arterial flow to the liver during pancreaticoduodenectomy often results in serious short and long-term consequences. Immediate restoration of arterial flow is indicated whenever technically feasible and may prevent early life-threatening complications as well as late biliary stenosis.
Topics: Hepatic Artery; Humans; Intraoperative Complications; Pancreatectomy; Pancreaticoduodenectomy; Postoperative Complications; Vascular System Injuries
PubMed: 28668523
DOI: 10.1016/j.jviscsurg.2017.05.013 -
Deutsches Arzteblatt International Jul 2016If conservative treatment of chronic pancreatitis is unsuccessful, surgery is an option. The choice of the most suitable surgical method can be difficult, as the... (Review)
Review
BACKGROUND
If conservative treatment of chronic pancreatitis is unsuccessful, surgery is an option. The choice of the most suitable surgical method can be difficult, as the indications, advantages, and disadvantages of the available methods have not yet been fully documented with scientific evidence.
METHODS
In April 2015, we carried out a temporally unlimited systematic search for publications on surgery for chronic pancreatitis. The target parameters were morbidity, mortality, pain, endocrine and exocrine insuffi - ciency, weight gain, quality of life, length of hospital stay, and duration of urgery. Differences between surgical methods were studied with network meta-analysis, and duodenum-preserving operations were compared with partial duodenopancreatectomy with standard meta-analysis.
RESULTS
Among the 326 articles initially identified, 8 randomized controlled trials on a total of 423 patients were included in the meta-analysis. The trials were markedly heterogeneous in some respects. There was no significant difference among surgical methods with respect to perioperative morbidity, pain, endocrine and exocrine insufficiency, or quality of life. Duodenumpreserving procedures, compared to duodenopancreatectomy, were associated with a long-term weight gain that was 3 kg higher (p <0.001; three trials), a mean length of hospital stay that was 3 days shorter (p = 0.009; six trials), and a duration of surgery that was 2 hours shorter (p <0.001; five trials).
CONCLUSION
Duodenum-preserving surgery for chronic pancreatitis is superior to partial duodenopancreatectomy in multiple respects. Only limited recommendations can be given, however, on the basis of present data. The question of the best surgical method for the individual patient, in view of the clinical manifestations, anatomy, and diagnostic criteria, remains open.
Topics: Adult; Comorbidity; Evidence-Based Medicine; Exocrine Pancreatic Insufficiency; Female; Hospital Mortality; Humans; Length of Stay; Male; Middle Aged; Operative Time; Pancreatectomy; Pancreatitis, Chronic; Postoperative Complications; Prevalence; Risk Factors; Survival Rate; Treatment Outcome
PubMed: 27545699
DOI: 10.3238/arztebl.2016.0489 -
Pancreas Jul 2021Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT)...
OBJECTIVE
Gastrointestinal bleeding (GIB) is an uncommon complication after abdominal surgery. Given the unique risks in the total pancreatectomy with islet autotransplant (TPIAT) population, we aimed to describe this population's incidence of postoperative GIB.
METHODS
Prospectively collected data on patients who underwent a TPIAT from 2001 to 2018 at the University of Minnesota were reviewed for postoperative GIB. Each GIB patient was matched to a control patient and compared for medical, medication, and social history and for clinical outcomes.
RESULTS
Sixty-eight patients developed a GIB (12.4%) at median time after surgery of 17 months. Etiologies included the following: anastomotic ulcer (35%), Clostridium difficile (4%), gastric or duodenal ulcers (9%), esophagitis/gastritis (10%), hemorrhoids (3%), inflammatory bowel disease (4%), Mallory-Weiss tears (1%), and unknown (29%). During diagnostic workup, 87% had an endoscopic procedure and 3% underwent imaging. Seven patients required an operation (10%), 1 required an open embolization (1%), and 13 required endoscopic treatments (19%). Patients with a GIB were more likely to die (15% vs 5%, P = 0.055).
CONCLUSIONS
Twelve percent of patients developed a GIB after TPIAT. One third of those had an undefined etiology despite endoscopy. The need for intervention was high (30%).
Topics: Adult; Female; Gastrointestinal Hemorrhage; Humans; Islets of Langerhans Transplantation; Male; Middle Aged; Pancreatectomy; Postoperative Complications; Prospective Studies; Retrospective Studies; Risk Assessment; Risk Factors; Transplantation, Autologous; Young Adult
PubMed: 34347732
DOI: 10.1097/MPA.0000000000001842