Regional oncology network between pancreatic centers safeguards waiting times for pancreatoduodenectomy.

Pancreatoduodenectomy (PD) is increasingly performed in high-volume centers, which may compromise waiting times. The aim of this study was to evaluate patient flow and outcome of PD within a regional oncology network of two high-volume centers. A post hoc analysis of a partially retrospective and prospective database was performed of all patients who underwent PD for pancreatic or periampullary neoplasms in both centers of the Gastrointestinal Oncology Center Amsterdam, a collaboration between an academic center and affiliated general teaching hospital, from 2010 to 2014. Outcomes included waiting time to surgery and postoperative morbidity and mortality. A total of 525 PDs were performed, 329 in the academic center (annual volume 66) and 196 in the teaching hospital (annual volume 39). Neoadjuvant treatment was more often used in the academic center, other baseline characteristics were similar. Overall time to surgery was 26 days, which was significantly less in the teaching hospital. The major postoperative morbidity rate was 38.3% (n = 201), and the 30- and 90-day mortality was 2.3% and 3.6%. A regional oncology network between an academic center and a general teaching hospital for PD can be an attractive option to safeguard waiting times in selected patients, without compromising outcome.

Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2).

OBJECTIVE: The aim of the study was to assess feasibility and outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LPD). BACKGROUND: Whereas expert centers have reported promising outcomes of LPD, nationwide analyses have raised concerns on its safety, especially during the learning curve. Multicenter, structured LPD training programs reporting outcomes including the first procedures are lacking. No LPD had been performed in the Netherlands before this study. METHODS: During 2014-2016, 8 surgeons from 4 high-volume centers completed the Longitudinal Assessment and Realization of Laparoscopic Pancreatic Surgery (LAELAPS-2) training program in LPD, including detailed technique description, video training, and proctoring. In all centers, LPD was performed by 2 surgeons with extensive experience in pancreatic and laparoscopic surgery. Outcomes of all LPDs were prospectively collected. RESULTS: In total, 114 patients underwent LPD. Median pancreatic duct diameter was 3 mm [interquartile range (IQR = 2-4)] and pancreatic texture was soft in 74% of patients. The conversion rate was 11% (n = 12), median blood loss 350 mL (IQR = 200-700), and operative time 375 minutes (IQR = 320-431). Grade B/C postoperative pancreatic fistula occurred in 34% of patients, requiring catheter drainage in 22% and re-operation in 2%. A Clavien-Dindo grade ≥ III complication occurred in 43% of patients. Median length of hospital stay was 15 days (IQR = 9-25). Overall, 30-day and 90-day mortality were both 3.5%. Outcomes were similar for the first and second part of procedures. CONCLUSIONS: This LPD training program was feasible and ensured acceptable outcomes during the learning curve in all centers. Future studies should determine whether such a training program is applicable in other settings and assess the added value of LPD.

Tumor manipulation during pancreatic resection for pancreatic cancer induces dissemination of tumor cells into the peritoneal cavity: a systematic review.

BACKGROUND: Intraoperative tumor manipulation may induce the dissemination of occult peritoneal tumor cells (OPTC) into the peritoneal cavity. METHODS: A systematic review was performed in the PubMed, Embase and Cochrane databases from inception to March 15, 2017. Eligible were studies that analyzed the presence of OPTC in peritoneal fluid, by any method, both before and after resection in adults who underwent intentionally curative pancreatic resection for histopathologically confirmed pancreatic ductal adenocarcinoma in absence of macroscopic peritoneal metastases. RESULTS: Four studies with 138 patients met the inclusion criteria. The pooled rate of OPTC prior to tumor manipulation was 8% (95% CI 2%-24%). The pooled detection rate of OPTC in patients in whom OPTC became detectable only after tumor manipulation was 33% (95% CI 15-58%). Only one study (28 patients) reported on survival, which was worse in patients with OPTC (median 11.1 months versus 30.3 months; p = 0.030). CONCLUSION: This systematic review suggests that tumor manipulation induces OPTC in one third of patients with pancreatic cancer. Since data on survival are lacking, future studies should determine the prognostic consequences of tumor manipulation, including the potential therapeutic effect of 'no-touch' and minimally invasive resection strategies.

Minimally Invasive Versus Open Pancreatoduodenectomy: Systematic Review and Meta-analysis of Comparative Cohort and Registry Studies.

OBJECTIVE: This study aimed to appraise and to evaluate the current evidence on minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy only in comparative cohort and registry studies. BACKGROUND: Outcomes after MIPD seem promising, but most data come from single-center, noncomparative series. METHODS: Comparative cohort and registry studies on MIPD versus open pancreatoduodenectomy published before August 23, 2015 were identified systematically and meta-analyses were performed. Primary endpoints were mortality and International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula (POPF). RESULTS: After screening 2293 studies, 19 comparative cohort studies (1833 patients) with moderate methodological quality and 2 original registry studies (19,996 patients) were included. For cohort studies, the median annual hospital MIPD volume was 14. Selection bias was present for cancer diagnosis. No differences were found in mortality [odds ratio (OR) = 1.1, 95% confidence interval (CI) = 0.6-1.9] or POPF [(OR) = 1.0, 95% CI = 0.8 to 1.3]. Publication bias was present for POPF. MIPD was associated with prolonged operative times [weighted mean difference (WMD) = 74 minutes, 95% CI = 29-118], but lower intraoperative blood loss (WMD = -385 mL, 95% CI = -616 to -154), less delayed gastric emptying (OR = 0.6, 95% = CI 0.5-0.8), and shorter hospital stay (WMD = -3 days, 95% CI = -5 to -2). For registry studies, the median annual hospital MIPD volume was 2.5. Mortality after MIPD was increased in low-volume hospitals (7.5% vs 3.4%; P = 0.003). CONCLUSIONS: Outcomes after MIPD seem promising in comparative cohort studies, despite the presence of bias, whereas registry studies report higher mortality in low-volume centers. The introduction of MIPD should be closely monitored and probably done only within structured training programs in high-volume centers.

Ganglion and Synovial Cyst of the Temporomandibular Joint: A Case Report and Literature Review.

Ganglion and synovial cysts of the temporomandibular joint (TMJ) are rare. Although histopathological findings differ, clinical presentation is comparable. This study adds a case report of a ganglion of the TMJ to existing literature and a review of all available case reports on ganglion and synovial cysts of the TMJ. Including our own case report, we reviewed 49 cases of ganglion and synovial cysts of the TMJ. They occurred in a female:male ratio of 3:1, at an median age of 46 years (range, 11-64 years). Patients mainly presented with preauricular swelling and pain. After imaging, the ganglion or synovial cyst was most commonly excised under general anesthesia. No recurrences were described.