Laparoscopic versus open distal pancreatectomy for nonfunctioning pancreatic neuroendocrine tumors: a large single-center study.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) account for 1-2% of all pancreatic neoplasms. Nonfunctioning PNETs (NF-PNETs) account for 60-90% of all PNETs. Laparoscopic distal pancreatectomy (LDP) is becoming the treatment of choice for benign lesions in the body and tail of the pancreas. However, LDP has not yet been widely accepted as the gold standard for NF-PNETs. The purpose of this study is to evaluate the clinical and oncologic outcomes after laparoscopic versus open distal pancreatectomy (ODP) for NF-PNETs. METHODS: Between April 1995 and September 2016, 94 patients with NF-PNETs underwent open or laparoscopic distal pancreatectomy at Samsung Medical Center. Patients were divided into two groups: those who underwent LDP and those who underwent ODP. Both groups were compared in terms of clinical and oncologic variables. RESULTS: LDP patients had a significantly shorter hospital stay compared with ODP patients, amounting to a mean difference of 2 days (p < 0.001). Overall complication rates did not differ significantly between the ODP and LDP groups (p = 0.379). The 3-year overall survival rates in the ODP and LDP groups were 93.7 and 100%, respectively (p = 0.069). CONCLUSIONS: In this study, LDP for NF-PNETs had similar oncologic outcomes compared with ODP. In addition, LDP was associated with a shorter hospital stay compared with ODP. Therefore, LDP is a safe and effective procedure for patients with NF-PNETs. A multicenter study and a randomized controlled trial are needed to better assess the clinical and oncologic outcomes.

Long-term outcomes following en bloc resection for pancreatic ductal adenocarcinoma of the head with portomesenteric venous invasion.

BACKGROUND: The aim of this study is to clarify the prognostic influence of venous resection of the portal vein (PV) or superior mesenteric vein (SMV) on long-term outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) of the head with suspected vascular invasion. METHODS: From May 1995 to December 2014, a total of 557 patients underwent surgery with curative intent for pancreatic cancer of the head. RESULTS: Among 557 patients, 106 (19%) underwent pancreaticoduodenectomy (PD) with PV-SMV resection and 89 (75.5%) of these patients were confirmed to have true pathological invasion. The 5-year overall survival rate in patients underwent PV-SMV resection was significantly lower compared with those who did not (18.7% versus 24.3%; p = 0.002). Patients with negative resection margins who underwent PV-SMV resection had a better prognosis than those with positive resection margins who did not undergo PV-SMV resection with positive resection margins (17% versus 6.3% in 5-year overall survival rate; p = 0.003). The overall morbidity rate was not significantly different between PV-SMV resection group and no PV-SMV resection group (p = 0.064). On multivariate analysis, margin status, advanced T stage (3 or 4), lymph node metastasis, and adjuvant therapy were independent prognostic factors for survival. CONCLUSION: PV-SMV resection was related to lower overall survival. However, on multivariate analysis, margin status was a more important prognostic factor than PV-SMV resection and true pathological invasion for survival. Therefore, en bloc PV-SMV resection should be performed when PV-SMV invasion is suspected to achieve R0 resection.

Can surgical treatment be justified for neuroendocrine carcinoma of the gallbladder?

Clinical features and treatment of GB neuroendocrine carcinoma (GB-NEC) are not well understood. This study aimed to analyze clinical outcomes of GB-NEC and verify the oncologic benefit of surgical treatment.From October 1994 to December 2014, the medical records of 31 patients with GB-NEC at a single center were retrospectively reviewed. There were 18 inoperable cases due to distant metastasis, including 7 of best supportive care (Tx.1) and 11 of non-operative palliative treatment (Tx.2). 4 patients received non-curative, palliative resection (Tx.3). Only 9 patients were able to undergo curative-intent resection (Tx.4).Among the 31 patients with GB-NEC, preoperative mean value of carbohydrate antigen 19-9 (CA 19-9) was 74.8 ±â€Š156.1 U/mL and the median overall survival time was 10 months (range 7.0-12.0 months). Of these, 21 (67.7%) patients received systemic treatment. Among 9 patients who underwent curative-intent resection (Tx.4), 9 patients had poorly differentiated cancer cells and 7 patients received radical cholecystectomy. 6 patients had adjuvant treatment including concurrent chemoradiation therapy (CCRT) or chemotherapy alone. The recurrence rate was 88.9%. The median overall survival between 4 groups was as follows: 4.0 (3.0-18.0) months in Tx.1 (n = 7) versus 9.0 (3.0-21.0) months in Tx.2 (n = 11) versus 11.0 (3.0-15.0) months in Tx.3 (n = 4) versus 23.0 (8.0-34.0) months in Tx.4 (n = 9), respectively. Significant differences in median overall survival time existed between Tx.2 and Tx.4; 9 (3.0-21.0) months versus 23.0 (8.0-34.0) months (P = .017).Most GB-NECs show poor biologic behavior. Nonetheless, curative-intent resection could possibly promote longer survival than other treatment modalities for GB-NEC. Efforts to undergo curative resection through early detection and development of adjuvant treatment are needed.

Actual long-term outcome of T1 and T2 pancreatic ductal adenocarcinoma after surgical resection.

BACKGROUND: The prognosis for patients with pancreatic cancer is extremely poor. The diagnosis of pancreatic ductal adenocarcinoma at an early stage is uncommon. The purpose of this study was to analyze the clinicopathological characteristics of patients with pathologically proven pancreatic ductal adenocarcinoma following surgical resection and their actual 5 year survival rates, especially for those with T1 and T2 early stage cancer. METHODS: Retrospective analysis was performed for 433 patients with pancreatic ductal adenocarcinoma who underwent resection at Samsung medical center between May 1995 and December 2010. The actual 5 year survival rates and prognostic factors were analyzed. RESULTS: Multivariate analysis showed that positive resection margin, poor differentiation, large tumor size, large amount of blood loss, and T3/T4 were independent prognostic factors on overall survival. The median survival for T1/T2 stage was 71.7 months compared to 16.1 months for those with T3/T4 stage. The actual 5 year survival rates for T1/T2 and T3/T4 stages were 66.7% and 18.4%, respectively. CONCLUSIONS: T stage is one of the strongest independent prognostic factor for overall survival of patients with pancreatic cancer. T1/T2 pancreatic ductal adenocarcinoma showed good survival outcome. Therefore, additional efforts are needed to improve the screening for early detection.

Beginner Surgeon's Initial Experience with Distal Subtotal Gastrectomy for Gastric Cancer Using a Minimally Invasive Approach.

PURPOSE: Minimally invasive gastrectomy (MIG), including laparoscopic distal subtotal gastrectomy (LDG) and robotic distal subtotal gastrectomy (RDG), is performed for gastric cancer, and requires a learning period. However, there are few reports regarding MIG by a beginner surgeon trained in MIG for gastric cancer during surgical residency and fellowship. The aim of this study was to report our initial experience with MIG, LDG, and RDG by a trained beginner surgeon. MATERIALS AND METHODS: Between January 2014 and February 2015, a total of 36 patients (20 LDGs and 16 RDGs) underwent MIG by a beginner surgeon during the learning period, and 13 underwent open distal subtotal gastrectomy (ODG) by an experienced surgeon in Bundang CHA Medical Center. Demographic characteristics, operative findings, and short-term outcomes were evaluated for the groups. RESULTS: MIG was safely performed without open conversion in all patients and there was no mortality in either group. There was no significant difference between the groups in demographic factors except for body mass index. There were significant differences in extent of lymph node dissection (LND) (D2 LND: ODG 8.3% vs. MIG 55.6%, P=0.004) and mean operative time (ODG 178.8 minutes vs. MIG 254.7 minutes, P<0.001). The serial changes in postoperative hemoglobin level (P=0.464) and white blood cell count (P=0.644) did not show significant differences between the groups. There were no significant differences in morbidity. CONCLUSIONS: This study showed that the operative and short-term outcomes of MIG for gastric cancer by a trained beginner surgeon were comparable with those of ODG performed by an experienced surgeon.