Protective peritoneal patch for arteries during pancreatoduodenectomy: good value for money.

PURPOSE: This study proposes and details a simple and inexpensive protective technique of wrapping the hepatic and gastroduodenal artery stumps with a peritoneal patch during pancreatoduodenectomy (PD) in order to decrease post-pancreatectomy hemorrhage (PPH). METHODS: Among the 85 patients who underwent PD between July 2020 and March 2021, 16 patients with high-risk pancreatic anastomosis received a peritoneal patch. The Updated Alternative Fistula Risk Score (ua-FRS) was calculated. Post-operative pancreatic fistula (POPF) and PPH were diagnosed and graded according to the International Study Group of Pancreatic Surgery. The mortality rate was calculated up to 90 days after PD. RESULTS: The mean ua-FRS of the 16 patients was 43% (range: 21-63%). Among them, 6 (38%) experienced clinically relevant-POPF, and a PPH was observed in two patients (13%). In these two patients who required re-intervention, the peritoneal patch was remarkably intact, and neither the gastroduodenal stump nor hepatic artery was involved. None of the patients experienced 90-day mortality. CONCLUSION: Although the outcomes are encouraging, the evaluation of a larger series to assess the effectiveness of the peritoneal protective patch for arteries in a high-risk pancreatic anastomosis is ongoing.

The Theory and Practice of Pancreatic Surgery in France.

OBJECTIVE: Measure the caseload of pancreatectomies that influences their short-term outcome, at a national level, and assess the applicability of a centralization policy. BACKGROUND: There is agreement that pancreatectomies should be centralized. However, previous studies have failed to accurately define a "high-volume" center. METHODS: French healthcare databases were screened to identify all adult patients who had elective pancreatectomies between 2007 and 2012. The patients' age, comorbidities, indication, and extent of surgery, and also the hospital administrative-type and location were retrieved. The annual-caseload of pancreatectomy was calculated for each hospital facility. The primary endpoint was 90-day mortality. Spline modeling was used to identify the different annual-caseload that influenced mortality. Logistic regressions were performed to assess if their influence was independent of confounders, and the accuracy of the model calculated. RESULTS: Overall, 22,366 patients underwent a pancreatectomy and the mortality was 8.1%. Two cut-offs were identified (25 and 65 per year): compared with centers performing >65 resections per year, the adjusted OR of mortality was 1.865 (1.529-2.276) in centers performing ≤25 resections per year and 1.234 (1.031-1.478) in those performing 26 to 65 resections per year. The average number of facilities performing ≤25, 26 to 65, and >65 pancreatectomies per year was 456, 20, and 9, respectively. The percentage of patients operated in these facilities was 56.6%, 19.9%, and 23.3%, respectively.For pancreaticoduodenectomies (12,670 patients; mortality 9.2%), there were 2 cut-offs (16 and 40 pancreaticoduodenectomies per year), and both were independent predictors of mortality (adjusted OR of 1.979 and 1.333). For distal pancreatectomies (7085 patients; 6.2% mortality), there were 2 cut-offs (13 and 25 distal pancreatectomies per year), but neither was an independent predictor of outcome (area under the receiver-operating characteristic curve of the model = 0.778). CONCLUSIONS: Centralization of pancreatic surgery is theoretically justified, but currently unrealizable. As the incidence of pancreatic cancer increases, there is an urgent need to improve the training of surgeons and develop both intermediate and high-volume centers.

Guidelines for time-to-event end-point definitions in trials for pancreatic cancer. Results of the DATECAN initiative (Definition for the Assessment of Time-to-event End-points in CANcer trials).

BACKGROUND: Using potential surrogate end-points for overall survival (OS) such as Disease-Free- (DFS) or Progression-Free Survival (PFS) is increasingly common in randomised controlled trials (RCTs). However, end-points are too often imprecisely defined which largely contributes to a lack of homogeneity across trials, hampering comparison between them. The aim of the DATECAN (Definition for the Assessment of Time-to-event End-points in CANcer trials)-Pancreas project is to provide guidelines for standardised definition of time-to-event end-points in RCTs for pancreatic cancer. METHODS: Time-to-event end-points currently used were identified from a literature review of pancreatic RCT trials (2006-2009). Academic research groups were contacted for participation in order to select clinicians and methodologists to participate in the pilot and scoring groups (>30 experts). A consensus was built after 2 rounds of the modified Delphi formal consensus approach with the Rand scoring methodology (range: 1-9). RESULTS: For pancreatic cancer, 14 time to event end-points and 25 distinct event types applied to two settings (detectable disease and/or no detectable disease) were considered relevant and included in the questionnaire sent to 52 selected experts. Thirty experts answered both scoring rounds. A total of 204 events distributed over the 14 end-points were scored. After the first round, consensus was reached for 25 items; after the second consensus was reached for 156 items; and after the face-to-face meeting for 203 items. CONCLUSION: The formal consensus approach reached the elaboration of guidelines for standardised definitions of time-to-event end-points allowing cross-comparison of RCTs in pancreatic cancer.

Cost of radiofrequency ablation in the treatment of hepatic malignancies.

OBJECTIVES: Our primary objective was to assess the cost of radio-frequency ablation (RFA) of hepatic malignancies and to compare it to hospital reimbursement paid in the French Prospective Payment System (PPS). PATIENTS AND METHODS: A series of 305 patients were enrolled into a prospective study. All resources used during the RFA-related hospital stay were recorded. Costs were assessed from the perspective of the health care providers and computed for four groups of patients: percutaneous RFA in an outpatient setting (group Ia, N=44), percutaneous RFA in an inpatient setting (group Ib, N=94), laparoscopic RFA (group II, N=44) and intraoperative RFA combined with resection (group III, N=120). RESULTS: Mean hospital costs were estimated at euro 1581 (group Ia), euro 3824 (group Ib), euro 8194 (group II) and euro 12967 (group III). Costs per stay without intensive care in these groups were respectively euro 1581, euro 3635, euro 6622 and euro 10905 and reimbursement (intensive care excluded) was euro 560, euro 3367, euro 9084 and euro 11780. CONCLUSION: In the French PPS, the cost of RFA is covered by lump sums paid to hospitals exclusively for intraoperative and laparoscopic RFA. For percutaneous RFA, which is the most frequent approach, reimbursement is highly insufficient.

Assessment of pathologic response after preoperative chemoradiotherapy and surgery in pancreatic adenocarcinoma.

PURPOSE: The benefits provided by preoperative chemoradiotherapy (CRT) in pancreatic ductular adenocarcinoma (PDA) are still controversial. However, in most reports from referral centers, improvement in local control and survival appears to be provided in selected patients. The aim of this retrospective study was to analyze the radiation-induced pathologic effects of preoperative CRT in patients with resectable PDA and determine the precise long-term outcome of the responding patients. METHODS AND MATERIALS: Between November 1996 and October 2003, 61 patients underwent preoperative CRT for resectable PDA. The tumor location was the pancreatic head in 49 patients and pancreatic body in 12 patients. Of the 61 patients, 21 (34.5%) did not undergo surgery because of disease progression and 40 (65.5%) underwent pancreatic resection, including pancreaticoduodenectomy in 32 (80%) and distal pancreatectomy in 8 (20%). RESULTS: A major pathologic response was noted in 9 patients, including three complete responses, and was found only in patients with tumor of the pancreatic head. The local control rate was similar in patients with and without a major pathologic response. Survival in patients with a major response was significantly greater than in those without a response or with a minor response. CONCLUSION: Major tumor downstaging can be provided by preoperative CRT in patients with resectable cephalic PDA. Survival appears to be significantly improved in selected patients.