Pancreatic Cancer: A Review of Current Treatment and Novel Therapies.

Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For those that present with localized disease, a multidisciplinary approach is necessary to maximize survival and optimize outcomes. The quality and safety of surgery for pancreatic cancer have improved in recent years with increasing adoption of minimally invasive techniques and surgical adjuncts. Systemic chemotherapy has also evolved to impact survival. It is now increasingly being utilized in the neoadjuvant setting, often with concomitant radiation. Increased utilization of genomic testing in metastatic pancreatic cancer has led to better understanding of their biology, thereby allowing clinicians to consider potential targeted therapies. Similarly, targeted agents such as PARP inhibitors and immune checkpoint- inhibitors have emerged with promising results. In summary, pancreatic cancer remains a disease with poor long-term survival. However, recent developments have led to improved outcomes and have changed practice in the past decade. This review summarizes current practices in pancreatic cancer treatment and the milestones that brought us to where we are today, along with emerging therapies.

Fluoroscopic placement of nasojejunal feeding tubes in COVID-19 patients in the prone position.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has caused an increase in patients requiring enteral feeding access while undergoing proning for severe acute respiratory distress syndrome (ARDS). We investigated the safety and feasibility of fluoroscopy-guided nasojejunal (NJ) feeding tube placement in the prone position. METHODS: This is a retrospective cohort study of all patients who underwent fluoroscopic placement of NJ feeding tubes at a single institution between March 2020 and December 2020. Primary end points were success rate and number of attempts. Chi-squared and Fischer exact tests were used to compare prone and supine groups. RESULTS: A total of 210 patients were included in the study: 53 patients received NJ feeding tubes while prone and 157 while supine. All but one patient in the prone group had ARDS secondary to COVID-19, whereas 47 (30.3%) had COVID-19 in the supine group. The rate of successful placement was 94.3% in the prone group and 100% in the supine group. Mean number of attempts was 1.1 (SD, ±0.4) in the prone and 1.0 (SD, ±0.1) in the supine group (P = .14). Prone patients had a longer median fluoroscopy time (69 s, interquartile range [IQR] = 92; vs 48 s, IQR = 43; P < .001) and received a higher radiation dose during the procedure (47 mGy, IQR = 50; vs 25 mGy, IQR = 33; P = .004). No procedural complications were reported. CONCLUSION: Fluoroscopy-guided NJ feeding tube placement in prone patients is feasible and safe. Patient positioning should not delay obtaining postpyloric feeding access.

Ileal Pouch Anal Anastomosis (IPAA) for colitis; development of Crohn's and Pouchitis.

BACKGROUND: Chronic pouchitis and Crohn's disease after Ileal pouch anal anastomosis (IPAA) for ulcerative colitis could be a larger issue than previously reported. METHODS: All patients receiving care for their IPAA over a 10-year period at a community hospital were included. Primary outcomes were incidence of Crohn's disease and pouchitis. RESULTS: The study included 380 IPAA patients. Indication for pouch creation was either UC (n = 362) or indeterminate colitis (n = 18). Cumulative incidence of Crohn's was 19.5%. Five-, 10- and 20-year incidence of Crohn's was 3.4%, 8.4% and 16.9%. Chronic pouchitis occurred in 28.7%. Mean time to pouchitis and Crohn's diagnosis was 8.4 (SD ± 8.0) and 11.6 (SD ± 7.5) years. Pouch failure occurred in 12.4%. Patients who developed Crohn's were more likely to suffer pouchitis and pouch failure (OR 3.5, 95%CI 2.0-6.0 and 5.3, 95%CI 2.8-10.1). CONCLUSION: During long term follow up, almost 20% are diagnosed with Crohn's contributing significantly to pouch failure.

[Sigmoid volvulus at the University Hospital of Iceland 2000-2013].

Backround Sigmoid volvulus is an uncommon cause of bowel obstruction in most western societies. Treatment options include colonoscopy in uncomplicated disease with elective surgery later on. The aim of this study was to assess what treatment sigmoid volvulus patients receive along with long-term outcomes at Landspitali University Hospital. Methods The study was retrospective. Patients diagnosed with sigmoid volvulus at Landspitali University Hospital from 2000-2013 were included. Information regarding age, sex, and duration of hospital stay, treatment, short and long-term outcomes were gathered. Results Forty-nine patients were included in the study, of which 29 men and 20 women. Mean age was 74 (25-93). One patient underwent acute surgery on first arrival due to signs of peritonitis. Others (n=48) were treated conservatively in the first attempt with colonoscopy (n=45), barium enema (n=2) and rectal tube (n=1). Three other patients underwent acute surgery due to failed colonoscopy, 8 patients had planned surgery during the index admission. Thirty-six patients were discharged after conservative treatment with colonoscopy (n=35), barium enema (n=1) or rectal tube (n=1). Two patients came in for elec-tive surgery later on. Twenty-two patients (61%) had recurrence. Median time to recurrence was 101 days (1-803). Disease-free probability in 3, 6 and 24 months was 66%, 55% and 22% respec-tively. Total disease related mortality was 10.2%. Mortality (30 days) after acute surgery was 25% (1/4) and 16,6% (3/18) after planned surgery. Conclusions Sigmoid volvulus has high recurrence rate if not treated operatively. Total mortality due to sigmoid volvulus at Landspitali is low but surgery related mortality high.

[Outcome after surgical resection for rectal cancer and its precursors in Landspitali University Hospital 2008-2012].

BACKGROUND: Rectal cancer makes up 2-3% of all cancers in Iceland and surgery is the mainstay of its treatment. Information regarding those who undergo resection of the rectum because of rectal cancer or its precursors in Iceland today is lacking. The aim of this study was to evaluate what kind of surgical treatment rectal cancer patients receive at Landspitali University Hospital along with peri-operative and long-term outcomes. METHODS: The study was retrospective. All patients undergoing total or partial resection of the rectum for rectal cancer or its precursor from 2008-2012 in Landspitali University hospital were included. Information regarding age, sex, surgery, neoadjuvant and adjuvant treatment along with reoperations and survival were gathered. RESULTS: The total number of patients included were 144. Mean age was 66 years (33-89). Neoadjuvant treatment was used in 65 (45%) cases. Most of the patients (65%) underwent anterior resection of the rectum, 21% abdominoperineal resection, 11% Hartmann´s procedure and 3% other surgery. Majority of the patients had a cancer diagnoses (88%) but 12% had dysplastic adenomas. An anastomosis was made in 67% of cases, others (33%) got a permanent stoma. Reoperation rate within 30 days was 12%. Thirty day and 1 year mortality were 0.7% and 6.2% respectively. Average follow up time was 56 months (1-98). Local recurrence rate was 7,1%, five year survival rate was 77%. CONCLUSION: The surgical treatment for rectal cancer in Landspitali is up to international standard. Perioperative and long-term outcomes are similar to what other authors have reported.

[Gallstone disease during pregnancy at Landspitali University Hospital 1990-2010].

INTRODUCTION: Gallstone disease in pregnant patients and their management in Iceland has not been studied. Management of these patients changed after the introduction of laparoscopic cholecystectomy. The aim of this study was to investigate the incidence, symptoms, diagnostic methods and management of gallstone disease during pregnancy at the National University Hospital of Iceland during the years 1990-2010. MATERIAL AND METHODS: This was a retrospective study and included all pregnant women admitted with gallstone diseases to the National University Hospital of Iceland which is the only tertiary hospital in Iceland. Information regarding age, symptoms and diagnostic methods for all women with gallstone disease along with BMI, ASA scores, pathology results and pregnancy related outcomes for women who underwent cholecystectomy were gathered. RESULTS: During the twenty year time period 77 women were admitted with gallstone disease in 139 admissions which makes incidence 0,1% amongst pregnant women. Diagnoses incuded biliary colic (n=59), common bile duct stones (n=10), acute cholecystitis (n=7) and gallstone pancreatitis (n=1). The most common symptom was RUQ pain (n=63). Two preterm births were a direct consequence of gallstone disease. Fifteen women underwent cholecystectomy during pregnancy and 17 during the six week period after birth. Mean BMI was 31,1 and median ASA score was 1. Pathology reports showed chronic inflammation (n=24) and acute inflammation (n=5), one case included gallstones without inflammation Adverse outcomes of surgeries were two cases of gallstones left in the common bile duct. No stillbirths or preterm births resulted from cholecystectomies during pregnancy. CONCLUSION: Gallstone disease during pregnancy is rare and readmissions are frequent. Pregnancy related complications are rare. Laparoscopic cholecystectomy is safe during pregnancy. Key words: gallstones, pregnancy, laparoscopic cholecystectomy. Correspondence: Pall Helgi Moller pallm@landspitali.is.