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BACKGROUND: The current AJCC 8th has been reported to have a poor ability to predict the prognosis in patients with resected borderline resectable pancreatic cancer and locally advanced pancreatic cancer following neoadjuvant chemotherapy. This study was aimed to develop an improved prognostic model by incorporating pathology and parameters of biologic response (BR). MATERIALS METHODS: A retrospective cohort study was conducted including patients who underwent curative-intent surgery following chemotherapy. We developed a modified ypT staging system and incorporated the BR, involving normalization of carbohydrate antigen 19-9 and reduction in the maximum standardized uptake value simultaneously after chemotherapy. The prognostic performance of the current pathologic system, modified pathologic system, and newly developed system incorporating pathology and BR were compared. RESULTS: In this study, 171 patients underwent surgery following chemotherapy. The modified T stage, which unified ypT2 and ypT3, demonstrated improved prognostic performance than the current staging system (area under the curve: 0.706 vs. 0.661). Biologic unresponsiveness was an independent prognostic factor for worse survival (hazard ratio 2.31, 95% confidence interval 1.50-3.55, P<0.001). The modified pathology with BR system demonstrated the highest discriminative ability in predicting 5-year overall survival than the current pathologic system (area under the curve: 0.785 vs. 0.661, P=0.010) and modified pathologic staging system (area under the curve: 0.785 vs. 0.706, P=0.002). CONCLUSIONS: The prognostic model, incorporating modified ypT staging and elevated carbohydrate antigen 19-9 levels and maximum standardized uptake value simultaneously, demonstrated improved results in predicting oncologic outcomes for patients who underwent surgery following neoadjuvant chemotherapy.
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BACKGROUND/PURPOSE: The eighth edition of the AJCC staging system introduced a shift in the staging of distal bile duct cancer (DBC), emphasizing the depth of invasion over adjacent organ invasion. This study aimed to evaluate the clinical impact of pancreatic invasion in pT1-stage DBC and identify prognostic factors for long-term survival. METHODS: This multicenter retrospective analysis encompassed DBC patients who underwent pancreaticoduodenectomy between 2009 and 2019 in six Korean tertiary centers, specifically those with final pathology confirming AJCC eighth edition T1 stage and intrapancreatic bile duct tumor origin. Primary endpoints were five-year recurrence-free survival (RFS) and overall survival (OS). Secondary objectives included the identification of prognostic determinants. RESULTS: This study involved 287 patients, comprising 190 without and 97 with pancreatic invasion. Pancreatic invasion did not significantly influence five-year OS and RFS rates (OS: without pancreatic invasion 69.9% vs. with pancreatic invasion 54.1%, p = .25; RFS: 56.3% vs. 55.4%, p = .97). Multivariate analysis highlighted male gender, age, lymphovascular invasion, and N stage as significant OS determinants. Notably, male gender, ampulla of Vater invasion, lymphovascular invasion, and N1 stage were also associated with RFS. CONCLUSIONS: In pT1 DBC, pancreatic invasion demonstrates no substantial impact on long-term prognosis, in accordance with the depth-based paradigm of the eighth edition AJCC staging system. The prognostic factors influencing OS were identified as male gender, age, lymphovascular invasion, and nodal metastasis.
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BACKGROUND: Determination of vessel resection in patients with pancreatectomy after neo-adjuvant chemotherapy remains controversial. The recently introduced computed tomography-based vascular burden index presents a potential solution to this challenge. This study aimed to evaluate the model performance for the prediction of vascular resection and pathological invasion. METHODS: Patients who underwent surgery after neo-adjuvant chemotherapy were included. Two independent reviewers measured the vascular tumour burden index around the adjacent artery (AVBI), and vein (VVBI). The area under the curve was compared to assess the predictive capacity of vascular burden index values and their changes for vascular resection and pathological vascular invasion. RESULTS: Among 252 patients, 179 and 73 had borderline resectable and locally advanced pancreatic cancer, respectively. Concurrent vessel resection and pathological vascular invasion were observed in 121 (48.0 %) and 42 (16.6 %) patients, respectively. In all patients, the VVBI (area under the curve: 0.872) and AVBI (0.911) after neo-adjuvant therapy significantly predicted vessel resection. In patients with vascular resection, the VVBI after neo-adjuvant chemotherapy (0.752) and delta value of the AVBI (0.706) demonstrated better performance for predicting pathological invasion of the resected vein. The regression of the AVBI and VVBI was an independent prognostic factor for survival (hazard ratio: 0.54, 95 % confidence interval: 0.34-0.85; P = 0.009) CONCLUSIONS: Regressed VVBI on serial computed tomography scans is useful for predicting vein resection and pathological venous invasion before surgery. The delta value of the AVBI may therefore be helpful for predicting pathological arterial invasion after neo-adjuvant chemotherapy.
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BACKGROUND/PURPOSE: Extranodal extension (ENE) is an established prognostic factor in various malignancies, affecting survival in pancreatic head cancer (PHC). However, its significance in pancreatic body/tail cancer (PBTC) remains unclear. Therefore, we aimed to investigate the impact of ENE on PTBC prognosis. METHODS: We analyzed data collected from electronic medical records of patients with PBTC who underwent distal pancreatectomy at a single center between January 2011 and December 2015. The patients were categorized based on ENE presence and prognostic implications were evaluated using Kaplan-Meier survival curves and Cox proportional hazards model. RESULTS: PBTC cases involving lymph node (LN) metastasis and ENE exhibited significantly lower disease-free (DFS) and overall survival (OS) rates compared to cases without LN metastasis or ENE (median DFS; N0, 23 months; LN+/ENE-, 10 months; LN+/ENE+, 5 months; p < .001). No statistically significant difference was observed in DFS and OS rates between patients with N1/N2 in the group without ENE and those with ENE+. Multivariate analysis confirmed ENE as a significant adverse prognostic factor. CONCLUSIONS: ENE significantly predicts poor prognosis in PBTC, particularly in cases with nodal metastasis. The current cancer staging system for PBTC should incorporate ENE status. Moreover, different staging systems should be considered for PHC and PBTC.
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Purpose: Clinical outcomes of surgery after neoadjuvant chemotherapy have not been investigated for locally advanced pancreatic cancer (LAPC), despite well-established outcomes in borderline resectable pancreatic cancer (BRPC). This study aimed to investigate the clinical outcomes of patients with LAPC who underwent curative resection following neoadjuvant chemotherapy. Materials and Methods: We retrospectively reviewed the records of patients diagnosed with pancreatic adenocarcinoma between January 2017 and December 2020. Results: Among 1,358 patients, 260 underwent surgery following neoadjuvant chemotherapy. Among 356 LAPC patients, 98 (27.5%) and 147 (35.1%) of 418 BRPC patients underwent surgery after neoadjuvant chemotherapy. Compared to resectable pancreatic cancer (resectable PC) with upfront surgery, both LAPC and BRPC exhibited higher rates of venous resection (28.6% vs. 49.0% vs. 4.0%), arterial resection (30.6% vs. 6.8% vs. 0.5%) and greater estimated blood loss (260.5 vs. 213.1 vs. 70.4 mL). However, hospital stay, readmission rates and postoperative pancreatic fistula rates (Grade B or C) did not differ significantly between LAPC, BRPC, and resectable PC. Overall and relapse-free survival did not differ significantly between LAPC and BRPC patients. The median overall survival was 37.3 months for LAPC and 37.0 months for BRPC. The median relapse-free survival was 22.7 months for LAPC and 26.0 months for BRPC. Conclusion: Overall survival time and postoperative complications in LAPC patients who underwent curative resection following neoadjuvant chemotherapy showed similar results to those of BRPC patients. Further research is needed to identify specific sub-populations of LAPC patients who benefit most from conversion surgery and to minimize postoperative complications.
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BACKGROUND: There is no standardized assessment for evaluating response although neoadjuvant chemotherapy (NAT) is widely accepted for borderline resectable or locally advanced pancreatic cancer (BRPC or LAPC). This study was aimed to evaluate NAT response using positron emission tomography (PET) with 2-deoxy-2-[fluorine-18]fluoro-D-glucose ( 18 F-FDG-PET/CT) parameters alongside carbohydrate antigen (CA) 19-9 levels. METHODS: Patients who underwent surgery after NAT for BRPC and LAPC between 2017 and 2021 were identified. The study assessed the prognostic value of PET-derived parameters after NAT, determining cutoff values using the K-adaptive partitioning method. It created four groups based on the elevation or normalization of PET parameters and CA19-9 levels, comparing survival between these groups. RESULTS: Of 200 eligible patients, FOLFIRINOX and gemcitabine-based NAT was administered in 166 and 34 patients, respectively (mean NAT cycles, 8.3). In a multivariate analysis, metabolic tumor volume (MTV) demonstrated the most robust performance in assessing response [hazard ratio (HR) 3.11, 95% confidence interval (CI) 1.73-5.58, P <0.001] based on cutoff value of 2.4. Patients with decreased MTV had significantly better survival than those with elevated MTV among individuals with CA19-9 levels less than 37 IU/l (median survival; 35.5 vs. 20.9 months, P <0.001) and CA19-9 levels at least 37 IU/l (median survival; 34.3 vs. 17.8 months, P =0.03). In patients suspected to be Lewis antigen negative, the predictive performance of MTV was found to be limited ( P =0.84). CONCLUSION: Elevated MTV is an influential prognostic factor for worse survival, regardless of post-NAT CA19-9 levels. These results could be helpful in identifying patients with a poor prognosis despite normalization of CA19-9 levels after NAT.
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Protocolos de Quimioterapia Combinada Antineoplásica , Terapia Neoadjuvante , Neoplasias Pancreáticas , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Carga Tumoral , Humanos , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Prognóstico , Carga Tumoral/efeitos dos fármacos , Estudos Retrospectivos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Fluordesoxiglucose F18 , Antígeno CA-19-9/sangue , Antígeno CA-19-9/metabolismo , Fluoruracila/administração & dosagem , Adulto , Oxaliplatina/administração & dosagem , Oxaliplatina/uso terapêutico , Leucovorina/administração & dosagem , Leucovorina/uso terapêutico , IrinotecanoRESUMO
BACKGROUND: Modified FOLFIRINOX (mFOLFIRINOX) is one of the standard first-line therapies in borderline resectable pancreatic cancer (BRPC) and locally advanced unresectable pancreatic cancer (LAPC). However, there is no globally accepted second-line therapy following progression on mFOLFIRINOX. METHODS: Patients with BRPC and LAPC (n = 647) treated with first-line mFOLFIRINOX between January 2017 and December 2020 were included in this retrospective analysis. The details of the treatment outcomes and patterns of subsequent therapy after mFOLFIRINOX were reviewed. RESULTS: With a median follow-up duration of 44.2 months (95% confidence interval [CI], 42.3-47.6), 322 patients exhibited disease progression on mFOLFIRINOX-locoregional progression only in 177 patients (55.0%) and distant metastasis in 145 patients (45.0%). The locoregional progression group demonstrated significantly longer post-progression survival (PPS) than that of the distant metastasis group (10.1 vs. 7.3 months, p = 0.002). In the locoregional progression group, survival outcomes did not differ between second-line chemoradiation/radiotherapy and systemic chemotherapy (progression-free survival with second-line therapy [PFS-2], 3.2 vs. 4.3 months; p = 0.649; PPS, 10.7 vs. 10.2 months; p = 0.791). In patients who received second-line systemic chemotherapy following progression on mFOLFIRINOX (n = 211), gemcitabine plus nab-paclitaxel was associated with better disease control rates (69.2% vs. 42.3%, p = 0.005) and PFS-2 (3.8 vs. 1.7 months, p = 0.035) than gemcitabine monotherapy. CONCLUSIONS: The current study showed the real-world practice pattern of subsequent therapy and clinical outcomes following progression on first-line mFOLFIRINOX in BRPC and LAPC. Further investigation is necessary to establish the optimal therapy after failure of mFOLFIRINOX.
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Adenocarcinoma , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/patologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Gencitabina , Estudos Retrospectivos , Adenocarcinoma/patologia , Fluoruracila/uso terapêutico , Leucovorina/uso terapêutico , Terapia Neoadjuvante , Progressão da Doença , Irinotecano , OxaliplatinaRESUMO
BACKGROUND: Management of early-stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder. METHODS: The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery. RESULTS: A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence-free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology. CONCLUSIONS: Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.
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Neoplasias da Vesícula Biliar , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Humanos , Neoplasias da Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/mortalidade , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Estudos Retrospectivos , Invasividade Neoplásica , Ducto Cístico/cirurgia , Ducto Cístico/patologia , Colecistectomia/métodos , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Adulto , Idoso de 80 Anos ou mais , Intervalo Livre de DoençaRESUMO
Background: Minimally invasive surgery (MIS) for cyst excision and Roux-en-Y hepaticojejunostomy (HJ) is widely performed for adult choledochal cysts. Few articles compared the robotic and laparoscopic approaches for choledochal cysts. Methods: Between 2014 and 2022, 157 patients who underwent MIS for choledochal cysts were retrospectively analyzed. Perioperative outcomes of patients who underwent totally robotic surgery, robot-assisted surgery, and laparoscopic surgery were compared, respectively. Also, postoperative outcomes of patients with robotic reconstruction and laparoscopic reconstruction during HJ were compared. Results: Perioperative outcomes were comparable between robotic and laparoscopic groups. The suturing technique for the anterior and posterior walls of the HJ differed significantly between the robotic and laparoscopic reconstruction groups (P = .001). However, there were no significant differences in postoperative outcomes, including total complications (P = .304), major complications (P = .411), and postoperative interventions (P = .411), between the two groups. Conclusions: The robotic and laparoscopic approaches for adult choledochal cysts have comparable surgical outcomes. In the MIS era, robotic surgery could be an alternative surgical option for adult choledochal cysts.
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Cisto do Colédoco , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Adulto , Humanos , Cisto do Colédoco/cirurgia , Estudos Retrospectivos , Anastomose em-Y de Roux/métodos , Laparoscopia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: This study compared the postoperative outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors based on the modified frailty index (mFI). MATERIALS AND METHODS: This retrospective study included 2212 patients who underwent MIDP for left-sided pancreatic tumors between 2005 and 2019. Postoperative outcomes, including complications (morbidity and mortality), were analyzed using mFI, and the participants were divided into two groups: frail ( n =79) and nonfrail ( n =2133). A subanalysis of 495 MIDPs for pancreatic ductal adenocarcinoma was conducted to compare oncological outcomes. RESULTS: Clinically relevant postoperative pancreatic fistula was significantly higher in the frail group than in the nonfrail group. A significant between-group difference was observed in overall complications with Clavien-Dindo classification grade ≥III. Furthermore, the proportion of all complications before readmission was higher in the frail group than in the nonfrail group. Among all readmitted patients, the frail group had a higher number of grade ≥IV patients requiring ICU treatment. The frail group's 90-day mortality was 1.3%; the difference was statistically significant (nonfrail: 0.3%, P =0.021). In the univariate and multivariate logistic regression analyses, mFI ≥0.27 (odds ratio 3.231, 95% CI: 1.889-5.523, P <0.001), extended pancreatectomy, BMI ≥30 kg/m 2 , male sex, and malignancy were risk factors for Clavien-Dindo classification grade ≥III. CONCLUSION: mFI is a potential preoperative tool for predicting severe postoperative complications, including mortality, in patients who have undergone MIDP for left-sided tumors.
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Carcinoma Ductal Pancreático , Fragilidade , Neoplasias Pancreáticas , Humanos , Masculino , Pancreatectomia/efeitos adversos , Estudos Retrospectivos , Fragilidade/complicações , Fragilidade/cirurgia , Carcinoma Ductal Pancreático/cirurgia , Carcinoma Ductal Pancreático/complicações , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
OBJECTIVES: This study aimed to show the clinical and oncologic outcomes of distal pancreatectomy with celiac axis resection (DP-CAR) from a high-volume single center and analyze them from diverse perspectives. METHODS: Forty-eight patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR were included in the study. The primary outcome was morbidity and 90-day mortality, and the secondary outcome was overall survival and disease-free survival. RESULTS: Morbidity (Clavien-Dindo classification grade ≥3) occurred in 12 patients (25.0%). Thirteen patients (27.1%) had pancreatic fistula grade B and 3 patients (6.3%) had delayed gastric emptying. The 90-day mortality was 2.1% (n = 1). The median overall survival was 25.5 months (interquartile range, 12.3-37.5 months) and median disease-free survival was 7.5 months (interquartile range, 4.0-17.0 months). During the follow-up period, 29.2% of participants survived for up to 3 years and 6.3% survived for up to 5 years. CONCLUSIONS: Despite its associated morbidity and mortality, DP-CAR should be considered as the only therapeutic option for pancreatic body and tail cancer with celiac axis involvement when carried out on carefully selected patients performed by a highly experienced group.
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Pancreatectomia , Neoplasias Pancreáticas , Humanos , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/tratamento farmacológico , Artéria Celíaca/cirurgia , Intervalo Livre de Doença , Estudos Retrospectivos , Neoplasias PancreáticasRESUMO
PURPOSE: The benefit of adjuvant chemotherapy following curative-intent surgery in pancreatic ductal adenocarcinoma (PDAC) patients who had received neoadjuvant FOLFIRINOX is unclear. This study aimed to assess the survival benefit of adjuvant chemotherapy in this patient population. Materials and Methods: This retrospective study included 218 patients with localized non-metastatic PDAC who received neoadjuvant FOLFIRINOX and underwent curative-intent surgery (R0 or R1) between January 2017 and December 2020. The association of adjuvant chemotherapy with disease-free survival (DFS) and overall survival (OS) was evaluated in overall patients and in the propensity score matched (PSM) cohort. Subgroup analysis was conducted according to the pathology-proven lymph node status. RESULTS: Adjuvant chemotherapy was administered to 149 patients (68.3%). In the overall cohort, the adjuvant chemotherapy group had significantly improved DFS and OS compared to the observation group (DFS: median, 13.8 months [95% confidence interval (CI), 11.0 to 19.1] vs. 8.2 months [95% CI, 6.5 to 12.0]; p < 0.001; and OS: median, 38.0 months [95% CI, 32.2 to not assessable] vs. 25.7 months [95% CI, 18.3 to not assessable]; p=0.005). In the PSM cohort of 57 matched pairs of patients, DFS and OS were better in the adjuvant chemotherapy group than in the observation group (p < 0.001 and p=0.038, respectively). In the multivariate analysis, adjuvant chemotherapy was a significant favorable prognostic factor (vs. observation; DFS: hazard ratio [HR], 0.51 [95% CI, 0.36 to 0.71; p < 0.001]; OS: HR, 0.45 [95% CI, 0.29 to 0.71; p < 0.001]). CONCLUSION: Among PDAC patients who underwent surgery following neoadjuvant FOLFIRINOX, adjuvant chemotherapy may be associated with improved survival. Randomized studies should be conducted to validate this finding.
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Adenocarcinoma , Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/cirurgia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Neoadjuvante , Estudos Retrospectivos , Carcinoma Ductal Pancreático/tratamento farmacológico , Carcinoma Ductal Pancreático/cirurgia , Quimioterapia Adjuvante , Neoplasias PancreáticasRESUMO
BACKGROUND/PURPOSE: Laparoscopic pancreaticoduodenectomy (PD) with major vein resection is a challenging procedure. Herein, we evaluated the feasibility and safety of laparoscopic vein resection in pancreatic head cancer with portal vein/superior mesenteric vein (PV/SMV) invasion, and compared the survival rate following laparoscopic surgery with that following open surgery. METHODS: We retrospectively reviewed the electronic medical records of all patients with pancreatic head cancer who underwent surgery performed by a single surgeon from January 2015 to December 2017. Kaplan-Meier curves were plotted to compare the disease-free survival, while Cox-proportional hazard models were used to analyze prognostic factors for survival. RESULTS: Among 76 patients, 63 underwent open PD and 13 underwent laparoscopic PD with PV/SMV resection. There was no significant difference in the rate of complications, including portal vein stenosis and portal vein thrombus, recurrence of tumors, or pathological outcomes after surgery between the groups. There was also no significant difference in disease-free survival (p = .803) between the two groups. Additionally, the surgical method was not an independent prognostic factor for disease-free survival. CONCLUSIONS: Laparoscopic PD with major vein resection can be feasibly performed in select patients with abutment and focal narrowing of the PV/SMV in pancreatic head cancer.
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Laparoscopia , Neoplasias Pancreáticas , Humanos , Pancreaticoduodenectomia/métodos , Resultado do Tratamento , Estudos Retrospectivos , Neoplasias Pancreáticas/patologia , Veia Porta/cirurgia , Veia Porta/patologia , Neoplasias PancreáticasRESUMO
Mixed adenoneuroendocrine carcinoma is defined as a tumor with a mixture of adenocarcinoma components and neuroendocrine neoplasm components. Each of these two components of mixed adenoneuroendocrine carcinoma accounts for at least 30% of all tumors. Mixed adenoneuroendocrine carcinoma might be located in the ampulla of Vater, a very rare location compared to other organs. Thus, its treatment and prognosis plans have not been established yet. We report three cases of mixed adenoneuroendocrine carcinoma occurring in the ampulla of Vater. Each patient had a different clinical course. In general, difficulty in preoperative diagnosis, risk of early recurrence, and poor disease course were main hallmarks of mixed adenoneuroendocrine carcinoma arising from the ampulla of Vater. However, one patient in this case report survived although she did not receive adjuvant chemotherapy due to her old age. Therefore, it is important to establish a careful treatment strategy for mixed adenoneuroendocrine carcinoma arising from the ampulla of Vater.
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BACKGROUND: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy (RDP) for pancreatic ductal adenocarcinoma (PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. METHODS: Patients who underwent RDP or laparoscopic distal pancreatectomy (LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. RESULTS: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time (209.7 vs. 163.2 min; P = 0.003), lower open conversion rate (0% vs. 4.8%; P < 0.001), higher cost (15 722 vs. 12 699 dollars; P = 0.003), and a higher rate of achievement of an R0 resection margin (90.5% vs. 61.9%; P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant inter-group difference (9.5% vs. 9.5%). The median disease-free survival (34.5 vs. 17.3 months; P = 0.588) and overall survival (37.7 vs. 21.9 months; P = 0.171) were comparable between the groups. CONCLUSIONS: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.
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Carcinoma Ductal Pancreático , Laparoscopia , Neoplasias Pancreáticas , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Pancreatectomia/efeitos adversos , Pontuação de Propensão , Resultado do Tratamento , Neoplasias Pancreáticas/patologia , Carcinoma Ductal Pancreático/cirurgia , Laparoscopia/efeitos adversos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Tempo de Internação , Neoplasias PancreáticasRESUMO
BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD) has been extended to periampullary cancers, but the oncologic outcome of MIPD for distal bile duct cancer (DBDC) has not been confirmed yet. METHODS: Patients who underwent pancreaticoduodenectomy (PD) for DBDC of stage I-IIb from 2015 to 2019 at a tertiary referral center were identified and divided into open PD (OPD) and MIPD groups, the latter including laparoscopic and robotic procedures. Survival was compared between the two groups after inverse probability of treatment weighting (IPTW) using predetermined factors, and exploratory mediation analysis was performed using surgery-derived outcomes. RESULTS: MIPD (n = 81) group had more female patients (46.9% vs 31.6%, p = 0.011) and longer operation time (366.2 min vs. 279.1 min, p < 0.001) than the OPD (n = 288) group before IPTW. Otherwise, intraoperative and immediate postoperative outcomes were comparable between the two groups. In oncologic outcomes, MIPD group showed comparable 3-year overall survival (78.2% vs 75.0%, p = 0.062) and recurrence-free survival (51.2% vs 53.4%, p = 0.871) rates with OPD group before IPTW, and MIPD was not related with survival (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.29-1.26, p = 0.18) and recurrence (HR 1.01, 95% CI 0.67-1.53, p = 0.949) after IPTW with consideration of potential mediators. Sensitivity analysis using propensity score matching also showed similar results for survival (HR 0.68, 95% CI 0.32-1.44, p = 0.312) and recurrence (HR 1.12, 95% CI 0.67-1.88, p = 0.653). CONCLUSION: MIPD and OPD groups showed similar postoperative and oncologic outcomes. MIPD could be a considerable treatment option without oncological compromise in high-volume centers.
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Neoplasias dos Ductos Biliares , Laparoscopia , Neoplasias Pancreáticas , Humanos , Feminino , Pancreaticoduodenectomia/métodos , Pancreatectomia , Neoplasias dos Ductos Biliares/cirurgia , Pontuação de Propensão , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/cirurgia , Estudos RetrospectivosRESUMO
Background: The aim of this study is to identify prognostic factors and the best candidates for neoadjuvant therapy among patients with resectable left-sided pancreatic ductal adenocarcinoma (PDAC) by analyzing the timing and pattern of recurrence following upfront surgery. Methods: This single-center retrospective study included patients with resectable left-sided PDAC who underwent upfront distal pancreatectomy from 2005 to 2015. A minimum P value approach was used to evaluate the optimal cutoff of early recurrence. The predictors of recurrence were assessed with Cox regression analysis. Results: Among 311 included patients, 241 (77.5%) had a recurrence at a median follow-up of 29.3 months. Systemic recurrence occurred in 194 patients (80.5%) and isolated local recurrence in 47 patients (19.5%). A recurrence-free survival cutoff of 12 months was selected to distinguish between early and late recurrence. The patients with early recurrence had a shorter median overall survival (16.1 vs. 39.9 months, P<0.001) and post-recurrence survival (9.6 vs. 17.2 months, P<0.001) than those with late recurrence. The patients with systemic recurrence had a shorter median overall survival (19.6 vs. 29.1 months, P=0.007) and post-recurrence survival (11.0 vs. 15.3 months, P=0.024) than those with an isolated local recurrence. In multivariable analysis, preoperative CA 19-9 ≥500 U/mL [odd ratio (OR) 2.037, P=0.035], radiologic splenic vessels invasion (OR 5.014, P<0.001), positive radial resection margin (OR 2.638, P<0.001), and no adjuvant chemotherapy (OR 2.084, P=0.001) were predictors of an early systemic recurrence. Conclusions: Radiologic splenic vessels invasion may be considered to indicate a biologically borderline status in patients with anatomically resectable left-sided PDAC. Future clinical trials of neoadjuvant therapy targeting these patients should be conducted.
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BACKGROUND/PURPOSE: The pathophysiology and associated factors of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) remain elusive. We aimed to investigate these factors, including the operation type, for NAFLD development after PD. METHODS: This historical cohort study included 786 consecutive patients treated with either classic Whipple operation or pylorus-preserving pancreaticoduodenectomy (PPPD) in Korea between 2012 and 2018. De novo NAFLD was determined based on hepatic attenuation in nonenhanced computed tomography during follow-up. RESULTS: Of the 786 patients, 216 (27.5%) had a newly developed NAFLD at 2 years after PD. The incidences of newly developed NAFLD at 0.5, 1, 1.5, and 2 years were 13 (1.7%), 41 (5.2%), 48 (6.1%), and 114 (14.5%), respectively. The Whipple group showed a significantly higher incidence of NAFLD than the PPPD group (40.3% vs 24.5%, P < .001). Seventeen patients (2.2%) had severe fatty liver with abnormal liver enzymes. Multivariable analysis revealed that Whipple operation (vs PPPD; adjusted odds ratio [AOR]: 1.92, P < .001) and high preoperative body mass index (vs normal; AOR: 1.71, P = .001) were independently associated with a higher risk of NAFLD. CONCLUSION: The incidence of NAFLD was 27.5% at 2 years after PD. Undergoing Whipple operation and high preoperative body mass index were significantly associated with de novo NAFLD development.
Assuntos
Hepatopatia Gordurosa não Alcoólica , Pancreaticoduodenectomia , Estudos de Coortes , Humanos , Pancreatectomia , Piloro , Fatores de RiscoRESUMO
BACKGROUND: We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15 years. METHODS: Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications. RESULTS: Minimally invasive distal pancreatectomy has steadily increased during the last 15 years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3. CONCLUSION: Minimally invasive distal pancreatectomy has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.
Assuntos
Laparoscopia , Neoplasias Pancreáticas , Humanos , Laparoscopia/métodos , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although surgery is the primary treatment for ampullary cancer (AC), the benefit of adjuvant chemotherapy (CTx) has not yet been confirmed. METHODS: AC patients who were administered 5-fluorouracil(FU)/leucovorin(LV)-based CTx after curative intent surgery between 2011 and 2019 were included. Prognosis was compared between the observation (OB) and CTx groups after propensity score matching (PSM) using perioperative variables to control differences in patient characteristics. RESULTS: Before PSM, of 475 patients, those in the CTx group (n = 281) had worse 5-year overall survival (OS) (82.1% vs. 78.5%, p = 0.017) and worse 5-year recurrence-free survival (RFS) (54.9% vs. 75.7%, p < 0.001) than those in the OB group (n = 194). In addition, the CTx group had a higher rate of poor prognostic factors such as a high T stage (p < 0.001), node metastasis (p < 0.001), and poor differentiation (p < 0.001). After PSM, perioperative outcomes were comparable. In addition, there were no significant differences in OS (hazard ratio [HR], 1.085; 95% confidence interval [CI], 0.688-1.710; p = 0.726) or RFS (HR, 0.883; 95% CI, 0.613 1.272; p = 0.505) between the CTx (n = 123) and OB (n = 123) groups even after stratification by TNM stage. Intestinal subtype showed better 5-year OS (83.7% vs 33.2%, p = 0.015) and RFS (46.5% vs 24.9%, p = 0.035) rate compared with pancreatobiliary/mixed subtype. CONCLUSION: Patients who received adjuvant chemotherapy based on 5-FU/LV showed comparable oncologic outcomes to patients in the OB group even after stratification by tumor stage. The patients with intestinal subtype showed oncologic benefit for adjuvant 5-FU/LV CTx compared with pancreatobiliary or mixed subtypes.