Preoperative cognitive function predicts survival in patients with resectable pancreatic ductal adenocarcinoma.

BACKGROUND: The purpose of this prospective study was to evaluate whether pre-surgery health-related quality of life (HRQoL) and subjectively rated symptom scores are prognostic factors for survival in patients with resectable pancreatic ductal adenocarcinoma (PDAC). METHODS: Patients undergoing pancreatic resection for PDAC completed the Edmonton Symptom Assessment System (ESAS) and the EORTC QLQ-C30 and QLQ-PAN26 questionnaires preoperatively. Patient, tumor and treatment characteristics, recurrence and survival were registered. RESULTS: Sixty-six consecutive patients underwent R0/R1 resection for PDAC. Baseline ESAS and EORTC questionnaire compliance was 44/66 (67%) with no statistically significant differences between compliers (n = 44) and non-compliers (n = 22) when comparing clinicopathological parameters and survival. Univariable analyses showed that three symptoms (nausea, dry mouth, cognitive function) and two clinicopathological factors (CA 19-9 > 400 U/ml, lymph node ratio > 0.1) were significantly associated with shorter survival (p < 0.05). In multivariable analysis, cognitive function was the only independent predictor for survival: hazard ratio = 0.35 (95%CI 0.13-0.93) for high vs low cognitive function. Median survival times for patients with high and low cognitive function were 21 and 10 months, respectively (p < 0.001). CONCLUSION: Presurgery cognitive function is a significant independent predictor of survival in patients with resectable PDAC. Thus, presurgery patient reported outcomes may provide as strong prognostic information as clinicopathological factors.

Improved survival and quality of life in patients undergoing R1 pancreatic resection compared to patients with locally advanced unresectable pancreatic adenocarcinoma.

OBJECTIVE: To prospectively record the clinical consequences of R1 resection of pancreatic adenocarcinoma compared to patients with locally advanced tumours not undergoing surgery. BACKGROUND: Surgery is the only potentially curative treatment of pancreatic cancer, and postoperative safety is increasing. The rate of R1 resections might also increase unintentionally as surgical procedures with curative goal become more comprehensive, and the clinical outcome requires further prospective evaluation. MATERIAL AND METHODS: Prospective observational cohort study from October 2008 to December 2010. Outcome after R1 resection (group 1, surgery, n = 32) and conservative palliative chemoradiation/endoscopy (group 2, no surgery, n = 56) is compared with survival and longitudinal patient-reported quality of life (QoL) as endpoints. QoL was assessed by the Edmonton Symptom Assessment System (ESAS). RESULTS: Demographic characteristics and tumour diameters were similar in both groups: 38.0 (31.3, 49.8) mm in group 1 versus 44.0 (39.6, 49.1) mm in group 2 (p = 0.18). Perioperative morbidity was 25% with no mortality. Disease-specific survival was 18.0 (14.5, 23.8) months in group 1 versus 8.1 (4.8, 10.1) months in group 2 (p < 0.0001). Overall survival was 11 (7.8, 14.4) months. Reduction in fatigue was significantly improved in the surgery group 6, 12, and 19 weeks after baseline, whereas reduction in global health was significantly better in group 2. CONCLUSION: Radical removal (R0 resection) is the primary aim of surgery, but also R1 resection seems to improve survival and QoL, compared to outcome in patients with locally advanced tumours not undergoing surgery.

Opportunities of improvement in the management of pancreatic and periampullary tumors.

Abstract Objective. The first objective of the present study was to identify opportunities of improvement for clinical practice, assessed by local quality indicators, then to analyze possible reasons why we did not reach defined treatment quality measures. The second objective was to characterize patients, considered unresectable according to present criteria, for future arrangement of interventional studies with improved patient selection. Material and methods. Prospective observational cohort study from October 2008 to December 2010 of patients referred to the authors' institution with suspected pancreatic or periampullary neoplasm. Results. Of 330 patients, 135 underwent surgery, 195 did not, 129 due to unresectable malignancies. The rest had benign lesions. Perioperative morbidity rate was 32.6%, mortality 0.7%. Radical resection (R0) was obtained in 23 (41.8%) of 55 patients operated for pancreatic adenocarcinoma and 6.3% underwent reconstructive vascular surgery. Diagnostic failure/delay resulted in unresectable carcinoma, primarily misconceived as serous cystic adenoma in two patients. One resected lesion turned out to be focal autoimmune pancreatitis. One case with misdiagnosed cancer was revised to be a pseudoaneurysm. Palliative treatment was offered to 144 patients with malignant tumors, 62 due to locally advanced disease and all pancreatic adenocarcinomas. Conclusions. Quality improvement opportunities were identified for patient selection and surgical technique: Too few patients underwent reconstructive vascular surgery. The most important quality indicators are those securing resectional, radical (R0) surgery. Altogether 143 patients (57.9%) of those with malignant tumors were found unresectable, most of these patients are eligible for inclusion in future interventional studies with curative and/or palliative intention.

Development and preliminary validation of the pancreatic cancer disease impact score.

OBJECTIVE: Patient-reported outcomes are important for clinical practice and research, and should reflect what patients perceive as important. The objective of this study was to develop and preliminarily validate a brief, patient-derived, disease-specific tool, the pancreatic cancer disease impact (PACADI) score. METHODS: The development was performed in two phases. Forty-one patients with confirmed pancreatic cancer (PC) selected dimensions of health related to the impact of the disease. A weighting of the eight most frequently reported dimensions was performed in a second sample of 80 PC patients who also rated the impact on eight numeric rating scales (NRS, range 0 to 10). The relative weights and the scores from the NRS were used to compute the PACADI score (range 0 to 10). The patients also completed Edmonton Symptom Assessment System (ESAS) and EQ-5D. RESULTS: Dimensions reported by more than 20% of the patients were included in the PACADI score (relative weights in parenthesis): pain/discomfort (0.16), fatigue (0.16), anxiety (0.15), bowel/digestive problems (0.14), loss of appetite (0.13), dry mouth (0.11), itchiness (0.08), and nausea (0.07). The PACADI score in the 80 PC patients had a mean (SD) value of 3.26 (2.06) (95% CI 2.80, 3.71), was moderately to strongly correlated to ESAS sense of well-being (r = 0.69) and EQ-5D (r = -0.52), and discriminated significantly between patients with and without PC. CONCLUSION: The PACADI score is a new eight-item, patient-derived, disease-specific measure. Preliminary validation regarding construct validity and discrimination encourages further validation in independent patient samples.

Gastric sleeve resection as day-case surgery: what affects the discharge time?

BACKGROUND: Sleeve gastrectomy, with its short operating time, is possible to perform as same-day surgery, with the most common reason for requiring overnight hospital stay being postoperative nausea and vomiting. OBJECTIVE: To demonstrate the feasibility and safety of sleeve gastrectomy as same-day surgery with regard to complication rate. Additionally, the study aimed to evaluate factors determining the duration of hospital stay, such as type of anesthesia, time of procedure, degree of postoperative nausea and pain, American Society of Anesthesiologists score, or previous abdominal surgery. SETTING: Nonacademic primary referral center. METHODS: A substudy of a single-center, double-blind, randomized controlled trial. Patients included in this study underwent sleeve gastrectomy and were randomized into 1 of the following 2 types of anesthesia: total intravenous anesthesia with propofol or desflurane. Primary endpoint was the number of patients discharged the same day as surgery. Secondary endpoints were unplanned telephone calls, readmission rate, and complication rate. Time of procedure was registered by the staff at the operation theatre. Visual analog scales score estimating patients' intensity of pain and nausea were completed at the postoperative unit, surgical ward, and 24 to 48 hours postoperatively. RESULTS: Ninety-three patients were included in the study. Fifty-nine (63%) were discharged the same day as surgery (32 desflurane and 27 total intravenous anesthesia), 30 patients (32%) were discharged 1 day after surgery, and 4 patients (4%) were discharged after >2 days (15 desflurane and 19 total intravenous anesthesia). The most common reasons for prolonged stay were pain, nausea, and fatigue. Statistical analyses showed no association between day of discharge and the type of anesthesia, time of the procedure, degree of postoperative nausea and vomiting, pain intensity, American Society of Anesthesiologists score, or previous abdominal surgery. CONCLUSION: Same-day surgery is feasible and safe in terms of low complication rate. The type of anesthesia, time of procedure, degree of postoperative nausea and vomiting and pain, American Society of Anesthesiologists score and previous abdominal surgery does not appear to affect length of hospital stay.

Pain and nausea after bariatric surgery with total intravenous anesthesia versus desflurane anesthesia: a double blind, randomized, controlled trial.

BACKGROUND: There is limited evidence-based knowledge regarding optimal anesthesia in obese patients. OBJECTIVE: To evaluate optimal anesthetic approach for patients undergoing bariatric surgery by determining and comparing peri- and postoperative outcomes in patients receiving intravenous anesthesia with propofol versus desflurane anesthesia. SETTING: Nonacademic primary referral center. METHODS: Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass between 2016 and 2017 were randomized into 1 of the following 2 types of anesthesia: intravenous anesthesia with propofol, or desflurane. Perioperative outcomes were registered by the operation staff. A form based on visual analog scale estimating the patient's intensity of pain and nausea was completed postoperatively at the postoperative unit, surgical ward, and 24 to 48 hours postsurgery. The primary outcome was postoperative nausea and vomiting or postoperative pain between treatment groups. The secondary outcome was to evaluate the "time of awakening," peritoneal stretch, and use of perioperative muscle relaxants. RESULTS: One hundred eighty-three patients were randomized to receive intravenous anesthesia (n = 90) or desflurane anesthesia (n = 93). Mean time ± standard deviation of surgery for both procedures was 41 ± 17 minutes, whereas mean time of awakening was 2 ± 2 minutes for both the intravenous anesthesia and desflurane group. There was no significant difference in visual analog scale for pain or for nausea and vomiting postoperatively, nor in the number of patients receiving muscle relaxants for peritoneal stretch between the 2 groups. CONCLUSIONS: We found no significant differences between the 2 anesthetic regimens regarding postoperative nausea and pain, awakening time, peritoneal stretch, or the use of perioperative muscle relaxants.