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1.
Anticancer Res ; 40(1): 387-392, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31892591

RESUMO

BACKGROUND/AIM: Locally advanced pancreatic cancer (LAPC) of the pancreatic body involving the celiac axis requires specialized treatment, including a subtotal distal pancreatectomy (SDP) with resection of the celiac axis (Appleby procedure). This study aimed to examine the value of the Appleby procedure, in current individualized treatment approaches, and to define its possible therapeutic impact for patients with LAPC. PATIENTS AND METHODS: 20 consecutive patients who underwent SDP with resection of the celiac axis between January 2005 and December 2018 were identified from a prospectively collected database and were matched with 20 patients experiencing SDP without resection of the celiac axis. Both perioperative parameters, as well as the overall postoperative course, were evaluated. RESULTS: The rate of perioperative complications in both groups was comparable (p=0.744). The rate of severe type C postoperative pancreatic haemorrhages (PPH) was significantly lower in patients with resection of the celiac axis compared to those without (p=0.035). CONCLUSION: The Appleby procedure may be considered as a safe and feasible treatment option with favorably fewer postoperative severe bleeding complications. Besides surgical expertise, such procedures, however, require an experienced interventional radiologist and should thus only be performed in high-volume centers.


Assuntos
Pancreatectomia , Adulto , Idoso , Feminino , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Análise de Sobrevida
2.
Khirurgiia (Mosk) ; (1): 14-24, 2020.
Artigo em Russo | MEDLINE | ID: mdl-31994495

RESUMO

OBJECTIVE: Adjustment of diagnostics and management of the surgical treatment of patients with intraductal papillary mucinous tumor of pancreas. MATERIAL AND METHODS: From 2012 to 2018, 45 patients with intraductal papillary mucinous tumor were observed. During the observation the ultrasound examination, contrast-enhanced computed tomography and magnetic resonance tomography with contrast were used. In 29 cases radical surgery was performed, nonradical in 1 case; case follow-up is chosen for 15 patients. RESULTS: Intraductal papillary mucinous tumor was diagnosed and the definition of the type of tumor was made on the base of 2 types of imaging methods. Intraductal papillary mucinous tumor type 1 was founded in 5 (11%), whereas intraductal papillary mucinous tumor type 2 was founded in 20 (44,5%) and intraductal papillary mucinous tumor type 3 was observed in 20 (44,5%) cases. Intraductal papillary mucinous tumor associated with carcinoma was observed in 16 cases. Pancreaticoduodenal resection was performed in 20, distal exsection of pancreas was performed in 4 cases (2 in open manner access, 2 in robot-assisted manner), pancreatic head resection was performed in 3 cases (1 in open manner access, 2 in laparoscopic access) and in 2 cases the duodenopancreatectomy was performed. Explorative laparotomy was performed in case of intraductal papillary mucinous tumor type 2 associated with mucilaginous carcinoma and miliary metastasis in the liver. Early postoperative complications were observed in 5 cases (16, 6%): biliary fistula (n=2), postoperative wound infection (n=2), arrosive hemorrhage type B in ISGPS (n=1, was treated in an X-ray endovascular manner). Case follow-up was chosen in 15 cases of intraductal papillary mucinous tumor over the course of 6 to 74 months and disease progression was not observed. CONCLUSION: Intraductal papillary mucinous tumor is a condition associated with high risk of malignant change and demands early disease detection. The treatment should be provided in medical centers that specialize in the pancreas deceases, where a full patient examination as well as a clear-eyed understanding of diagnostic information with the execution of desirable type of surgical intervention with the guaranty of achievement R0 condition can be offered.


Assuntos
Neoplasias Intraductais Pancreáticas/diagnóstico , Neoplasias Intraductais Pancreáticas/cirurgia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Humanos , Pâncreas/patologia , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Neoplasias Intraductais Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Pancreaticoduodenectomia/efeitos adversos
3.
Anticancer Res ; 39(12): 6799-6806, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810945

RESUMO

BACKGROUND/AIM: In order to overcome postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP), we have developed a new simple technique-Clip on Staple method. PATIENTS AND METHODS: In Clip on Staple method, pancreatic parenchyma was divided using a stapling device with a stepped-height staple design to make linear compression line, and thereafter, the full length of the staple line was reinforced by multiple clips. Clinical outcomes were retrospectively compared between Clip on Staple group (n=23) and Non-Clip group (n=38). RESULTS: The incidence of clinically relevant POPF (CR-POPF) was significantly lower in the Clip on Staple group than in the Non-Clip group (4.3 and 36.8%, p=0.005). Multivariate logistic regression analysis revealed that only Clip on Staple method was an independent predictive factor of a decrease in the occurrence of CR-POPF. CONCLUSION: The Clip on Staple method, a simple and easily applicable technique even in laparoscopic surgery, significantly reduced the occurrence of CR-POPF among patients undergoing DP.


Assuntos
Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Fístula Pancreática/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Instrumentos Cirúrgicos , Grampeamento Cirúrgico/métodos , Idoso , Feminino , Humanos , Incidência , Laparoscopia , Masculino , Pancreatectomia/métodos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Complicações Pós-Operatórias/etiologia , Análise de Regressão
4.
Medicine (Baltimore) ; 98(50): e18275, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852099

RESUMO

RATIONALE: Surgery for patients with multiple endocrine neoplasia type 1(MEN-1) related gastrinoma remains controversial and total pancreatectomy (TP) has rarely been performed. We reported a case of patient with MEN-1 related gastrinoma treated by TP. PATIENT CONCERNS: A 46-year-old female was admitted to our hospital due to abdominal distension and diarrhea for 2 years. The patient underwent pituitary tumor resection and kidney stone lithotripsy 10 years ago. DIAGNOSES: Abdominal computed tomography showed single lesion in the duodenum and multiple lesions throughout the pancreas. The patient's gastrin level was significantly increased (1080 pg/ml). These findings in combination with the pituitary tumor history suggested the presence of gastrinoma associated with MEN-1 syndrome. INTERVENTION: An exploratory laparotomy was performed. Intraoperative ultrasound confirmed the numerous tumors diffusely distributed throughout the pancreas and the patient eventually underwent TP. OUTCOMES: Twelve months later, the patient was hospitalized again for anastomotic fistula and underwent a partial gastrectomy, small bowel resection and drainage of the abscess. One month later, she received gastrostomy and jejunostomy due to digestive tract fistula, and died a month later (14 months after TP). LESSONS: There still might be the possibility of recurrence even after radical surgical resection of gastrinomas, and we suggest the need to measure the basal acid output and maintain regular anti-acid therapy in the long-term follow-up of patients with MEN-1 related gastrinoma.


Assuntos
Neoplasias Duodenais/etiologia , Gastrinoma/cirurgia , Neoplasia Endócrina Múltipla Tipo 1/etiologia , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Biópsia , Neoplasias Duodenais/diagnóstico , Evolução Fatal , Feminino , Gastrinoma/diagnóstico , Humanos , Pessoa de Meia-Idade , Neoplasia Endócrina Múltipla Tipo 1/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Tomografia Computadorizada por Raios X
5.
Am Surg ; 85(11): 1239-1245, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31775965

RESUMO

The purpose of this meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). PubMed, Web of Knowledge, and Ovid's database were searched for studies published in English language between January 1990 and December 2018. A meta-analysis was performed to compare the clinical outcomes of CP versus DP. Nineteen trials with 1440 patients were analyzed. Although there were no significant differences in the rate of intraoperative blood transfusion between two groups, CP costs more operative time as well as had more intraoperative blood loss than DP. Furthermore, the overall complication rate, pancreatic fistula rate, and the clinically significant pancreatic fistula rate were significantly higher in the CP group. On the other hand, CP had a lower risk of endocrine (odds ratio: 0.17; 95% confidence interval: 0.10, 0.29; P < 0.05) and exocrine insufficiency (odds ratio: 0.22; 95% confidence interval: 0.10, 0.48; P < 0.05). CP was associated with a higher pancreatic fistula rate, and it should be performed in selected patients who need preservation of the pancreas, which is of utmost importance.


Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Duração da Cirurgia , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/etiologia , Transfusão de Sangue/estatística & dados numéricos , Intervalos de Confiança , Diabetes Mellitus/etiologia , Humanos , Tempo de Internação , Resultado do Tratamento
6.
Medicine (Baltimore) ; 98(38): e17196, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31567967

RESUMO

BACKGROUND: The use of octreotide prophylaxis following pancreatic surgery is controversial. We aimed to evaluate the effectiveness of octreotide for the prevention of postoperative complications after pancreatic surgery through this systematic review and meta-analysis. METHODS: Literature databases (including the MEDLINE, EMBASE, and Cochrane databases) were searched systematically for relevant articles. Only randomized controlled trials (RCTs) were eligible for inclusion in our research. We extracted the basic information regarding the patients, intervention procedures, and all complications after pancreatic surgery and then performed the meta-analysis. RESULTS: Thirteen RCTs involving 2006 patients were identified. There were no differences between the octreotide group and the placebo group with regard to pancreatic fistulas (PFs) (relative risk [RR] = 0.79, 95% confidence interval [CI] = 0.62-0.99, P = .05), clinically significant PFs (RR = 1.01, 95% CI = 0.68-1.50, P = .95), mortality (RR = 1.21, 95% CI = 0.78-1.88, P = .40), biliary leakage (RR 0.84, 95% CI = 0.39-1.82, P = .66), delayed gastric emptying (RR = 0.83, 95% CI = 0.54-1.27, P = .39), abdominal infection (RR = 1.00, 95% CI = 0.66-1.52, P = 1.00), bleeding (RR = 1.16, 95% CI = 0.78-1.72, P = .46), pulmonary complications (RR = 0.73, 95% CI = 0.45-1.18, P = .20), overall complications (RR = 0.80, 95% CI = 0.64-1.01, P = .06), and reoperation rates (RR = 1.18, 95% CI = 0.77-1.81, P = .45). In the high-risk group, octreotide was no more effective at reducing PF formation than placebo (RR = 0.81, 95% CI = 0.67-1.00, P = .05). In addition, octreotide had no influence on the incidence of PF (RR = 0.38, 95% CI = 0.14-1.05, P = .06) after distal pancreatic resection and local pancreatic resection. CONCLUSION: The present best evidence suggests that prophylactic use of octreotide has no effect on reducing complications after pancreatic resection.


Assuntos
Fármacos Gastrointestinais/uso terapêutico , Octreotida/uso terapêutico , Pancreatectomia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Humanos , Pâncreas/cirurgia
7.
Transplant Proc ; 51(9): 3131-3135, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31611120

RESUMO

Liver cirrhosis can cause splenic artery aneurysms (SAA) that pose a threat to patients undergoing liver transplantation. However, liver transplantation with multiple visceral artery aneurysms including giant SAA caused by arterial fragility has never been reported. We describe a 36-year-old man with decompensated liver cirrhosis due to Wilson disease that was complicated by giant SAA and multiple aneurysms in the bilateral renal arteries caused by fibromuscular dysplasia (FMD). The maximal diameter of the triple snowball-shaped SAA was 11 cm. We planned a 2-stage strategy consisting of a splenectomy with distal pancreatectomy to treat the SAA and subsequent living donor liver transplantation (LDLT) to address the liver cirrhosis. This strategy was selected to prevent fatal postoperative infectious complications caused by the potential development of pancreatic fistula during simultaneous procedures and to histopathologically diagnose the arterial lesion before LDLT to promote safe hepatic artery reconstruction. However, a postoperative pancreatic fistula did not develop after a splenectomy with distal pancreatectomy, and the pathologic findings of the artery indicated FMD. The patient underwent ABO-identical LDLT with a right lobe graft donated by his brother. Other than postoperative rupture of the aneurysm in the left renal artery requiring emergency interventional radiology, the patient has remained free of any other arterial complications and continues to do well at 2 years after LDLT.


Assuntos
Aneurisma/etiologia , Displasia Fibromuscular/complicações , Degeneração Hepatolenticular/complicações , Transplante de Fígado , Artéria Esplênica/patologia , Adulto , Aneurisma/cirurgia , Humanos , Cirrose Hepática/etiologia , Cirrose Hepática/cirurgia , Doadores Vivos , Masculino , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Artéria Renal/patologia , Esplenectomia/efeitos adversos , Esplenectomia/métodos , Artéria Esplênica/cirurgia
8.
Khirurgiia (Mosk) ; (9): 93-98, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31532174

RESUMO

OBJECTIVE: To improve short- and long-term outcomes of locally advanced pancreatic body-tail cancer followed by major vessels invasion. MATERIAL AND METHODS: A case report of pure laparoscopic DP-CAR procedure with portal vein resection for locally advanced pancreatic body-tail cancer followed by severe abdominal pain in a 49-year-old patient is presented. RESULTS: Liver or stomach ischemia was not observed. Portal wall resection wasn't associated with any complication and resulted R0-resection. Postoperative period was complicated by Grade B pancreatic fistula. Preoperative abdominal pain completely disappeared after surgery. Surgery time was 330 min, intraoperative blood loss - 300 ml. The patient is currently undergoing FOLFIRINOX adjuvant chemotherapy. CT in 90 days after surgery confirmed no progression of disease or liver/stomach blood supply congestion. CONCLUSION: Modern technologies provide the opportunity to perform pure laparoscopic advanced surgical procedures with major vessels resection. Pure laparoscopic DP-CAR procedure with portal vein resection is effective and safe procedure that can be performed with all principles of open surgery and is associated with acceptable short- and long-term results.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Artéria Celíaca/cirurgia , Laparoscopia/métodos , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Veia Porta/cirurgia , Antineoplásicos/administração & dosagem , Fluoruracila/administração & dosagem , Humanos , Irinotecano/administração & dosagem , Leucovorina/administração & dosagem , Pessoa de Meia-Idade , Invasividade Neoplásica , Oxaliplatina/administração & dosagem , Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/patologia , Veia Porta/patologia
9.
BMC Surg ; 19(1): 108, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31409334

RESUMO

OBJECTIVE: We aimed to determine the impact of surgical experience and frequency of practice on perioperative morbidity and mortality in pancreatic surgery. METHODS: 1281 patients that underwent pancreatic resections from 1993 to 2013 were retrospectively analyzed using logistic regression models. All cases were stratified according to the surgeon's level of experience, which was based on the number of previously performed pancreatic resections and the extent of received supervision (novice: n <  20 / intensive; intermediate: n = 21-90 / decreasing; and experienced surgeon: n > 90 / none). Additional stratification was based on the frequency of practice (sporadic: 3 resections > 6 weeks, frequent: 3 resections ≤6 weeks). RESULTS: The novice and experienced categories were related to a decreased risk of postoperative pancreatic fistulas (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.82 and 0.54, 95% CI 0.36-0.82) and in-hospital mortality (OR 0.45, 95% CI 0.17-1.16 and 0.42, 95% CI 0.21-0.83) compared to the intermediate category. Frequent practice was associated with a significantly lower risk of delayed gastric emptying (OR 0.56, 95% CI 0.38-0.83), postpancreatectomy hemorrhage (OR 0.64, 95% CI 0.42-0.98) and in-hospital mortality (OR 0.45, 95% CI 0.24-0.87). CONCLUSIONS: Our results emphasize the importance of supervision within a pancreatic surgery training program. In addition, our data underline the need of a sufficient patient caseload to ensure frequent practice.


Assuntos
Competência Clínica , Pancreatectomia/efeitos adversos , Idoso , Feminino , Gastroparesia/etiologia , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pancreatectomia/métodos , Pancreatectomia/mortalidade , Fístula Pancreática/etiologia , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos
10.
BMC Surg ; 19(1): 115, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438917

RESUMO

BACKGROUND: The European Consensus 2018 established a new algorithm with absolute and relative criteria for intraductal papillary mucinous neoplasms of the pancreas (IPMN) management. The aim of this study was to validate these criteria and analyse the outcomes in function of the surgical procedure and IPMN subtype. METHODS: Clinical, radiological and surgical data (procedure, morbidity/mortality rates) of patients who underwent surgery for IPMN between 2007 and 2017. The predictive value of the different criteria was analysed. RESULTS: 124 patients (men 67%; mean age 65 years) underwent surgery for IPMN (n = 62 malignant tumours; 50%). Jaundice, cyst ≥4 cm and Wirsung duct size 5-9.9 mm or ≥ 10 mm were significantly associated with malignancy (4.77 < OR < 11.85 p < 0.0001). The positive predictive value of any isolated criterion ranged from 71 to 87%, whereas that of three relative criteria together reached 100%. The mortality and morbidity (grade III-IV complications according to the Dindo-Clavien classification) rates were 3 and 8%, respectively. Morbidity/mortality after duodenopancreatectomy and total pancreatectomy were significantly higher for benign IPMN (p = 0.01). CONCLUSION: Considering the morbidity associated with extended surgery, particularly for benign IPMN, the results of the present study suggest that high-risk surgery should be considered only in the presence of three relative criteria and including the surgery type in the decision-making algorithm.


Assuntos
Tomada de Decisão Clínica , Neoplasias Intraductais Pancreáticas/patologia , Neoplasias Intraductais Pancreáticas/cirurgia , Guias de Prática Clínica como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Humanos , Icterícia/patologia , Masculino , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Cisto Pancreático/patologia , Ductos Pancreáticos/patologia , Neoplasias Intraductais Pancreáticas/diagnóstico por imagem , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias , Radiografia , Estudos Retrospectivos
11.
Medicine (Baltimore) ; 98(29): e16455, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31335701

RESUMO

RATIONALE: About 8384 cases of solid pseudopapillary neoplasms (SPN) of pancreas have been published in English literature, from 1933 to 2018. This is a low-grade tumor that usually occurs in children but is rare in adults and, in exceptional cases, can show extrapancreatic localization. In this paper we present 2 unusual cases of SPNs, 1 with retroperitoneal location (case 1) and 1 that was firstly diagnosed as a G1 neuroendocrine tumor (NET) and showed hepatic metastases after 13 years (case 2). PATIENT CONCERNS: No symptoms in first case. The tumor was incidentally diagnosed, during ultrasound examination. In the second case, the metastasis was observed during regular follow-up. DIAGNOSES: The diagnosis was established based on the histological features and immunohistochemical profile that showed positivity for vimentin, nuclear ß-catenin, cyclin D1, CD10, and SRY-related high-mobility group box 11 and negativity for maspin. INTERVENTIONS: Surgical excision, in both cases. OUTCOMES: No recurrences in first case, at 5 months after diagnosis. Hepatic metastases in the second case, at 13 years after diagnosis, with portal invasion after another 15 months. LESSONS: Without a complex immunoprofile, SPN can be misdiagnosed as NET. SPN can be a low-grade tumor but long-time follow-up is mandatory to detect delayed metastases. A correct diagnosis is necessary for a proper therapeutic management.


Assuntos
Adenocarcinoma Papilar , Biomarcadores Tumorais/análise , Neoplasias Císticas, Mucinosas e Serosas , Tumores Neuroendócrinos/diagnóstico , Pâncreas/patologia , Neoplasias Pancreáticas , Adenocarcinoma Papilar/imunologia , Adenocarcinoma Papilar/patologia , Adenocarcinoma Papilar/fisiopatologia , Adenocarcinoma Papilar/terapia , Adulto , Ciclina D1/análise , Diagnóstico Diferencial , Feminino , Humanos , Imuno-Histoquímica , Pessoa de Meia-Idade , Neoplasias Císticas, Mucinosas e Serosas/imunologia , Neoplasias Císticas, Mucinosas e Serosas/patologia , Neoplasias Císticas, Mucinosas e Serosas/fisiopatologia , Neoplasias Císticas, Mucinosas e Serosas/terapia , Neprilisina/análise , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Neoplasias Pancreáticas/imunologia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/fisiopatologia , Neoplasias Pancreáticas/terapia , Prognóstico , Resultado do Tratamento , Vimentina/análise , beta Catenina/análise
13.
Int J Radiat Oncol Biol Phys ; 105(3): 606-617, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31306735

RESUMO

PURPOSE: Preoperative treatment is recommended for borderline resectable pancreatic ductal adenocarcinoma. However, the standard treatment has not yet been determined. We conducted a multicenter phase 2 study to investigate the efficacy of neoadjuvant treatment of sequential chemoradiation followed by chemotherapy. METHODS AND MATERIALS: All enrolled patients were treated by preoperative chemoradiation (a total dose of 50.4 Gy in 28 fractions and orally administered S-1 at 80 mg/m2 on the day of irradiation) followed by chemotherapy (administration of gemcitabine at 1000 mg/m2/dose on days 1, 8, and 15 in 3 cycles of 4 weeks) and attempted curative resection. The primary outcome was an R0 resection rate among patients who completed preoperative treatment and pancreatectomy. The threshold of the R0 resection rate was defined as 74% based on a previous study of up-front surgery. RESULTS: Forty-five patients were included. Twenty-one patients could not undergo pancreatectomy because of progressive diseases (n = 14), adverse events (n = 5), or consent withdrawal (n = 2), and 4 patients underwent additional resection after dropping out. The resection rates were 53.3% and 62.2% in the per-protocol set (PPS) and full analysis set (FAS) populations, respectively. The R0 resection rates were 95.8% (95% confidence interval, 78.9%-99.9%) and 96.4% (81.7%-99.9%) in the PPS and FAS populations, respectively. The median overall survival and progression-free survival of all the included patients were 17.3 and 10.5 months, respectively. The median survival time of the patients with pancreatectomy was significantly longer than that of the patients without pancreatectomy in the PPS (27.9 vs 12.3 months; P = .001) and FAS populations (32.2 vs 11.8 months; P < .001). CONCLUSIONS: This study revealed that a long duration of preoperative treatment of sequential chemoradiation followed by systemic chemotherapy provides a high rate of R0 resection and sufficient survival time in patients undergoing pancreatectomy.


Assuntos
Adenocarcinoma/terapia , Antimetabólitos Antineoplásicos/administração & dosagem , Quimiorradioterapia/métodos , Desoxicitidina/análogos & derivados , Terapia Neoadjuvante , Ácido Oxônico/administração & dosagem , Neoplasias Pancreáticas/terapia , Tegafur/administração & dosagem , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/patologia , Carcinoma Ductal Pancreático/diagnóstico por imagem , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/terapia , Desoxicitidina/administração & dosagem , Fracionamento da Dose de Radiação , Esquema de Medicação , Combinação de Medicamentos , Feminino , Humanos , Masculino , Recidiva Local de Neoplasia , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Complicações Pós-Operatórias , Critérios de Avaliação de Resposta em Tumores Sólidos , Análise de Sobrevida , Tomografia Computadorizada por Raios X , Resultado do Tratamento
14.
Surgery ; 166(3): 277-285, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31272811

RESUMO

BACKGROUND: It is difficult to successfully deliver multimodality therapy to patients with operable pancreatic cancer. Data on the natural history of such efforts are necessary for physicians to guide shared decision-making with patients and families. We report the survival of consecutive patients with borderline resectable pancreatic cancer who received neoadjuvant therapy before surgery. METHODS: Data regarding demographics, neoadjuvant therapy, surgery, pathology, and survival duration were abstracted on consecutive patients with borderline resectable pancreatic cancer diagnosed between 2009 and 2017 and not treated on available clinical trials. Borderline resectable pancreatic cancer was defined based on ≥1 of the following: local tumor anatomy, pretreatment serum carbohydrate antigen 19-9 >2,000 U/mL, and the presence of radiographic lesions indeterminate for metastases. RESULTS: Neoadjuvant therapy was delivered to 185 patients with borderline resectable pancreatic cancer who were not enrolled in competing clinical trials; 13 (7%) patients received chemoradiation, 12 (7%) received chemotherapy, and 160 (86%) received both. Of the 185 patients, 115 (62%) completed all intended neoadjuvant therapy and surgery; 81 (70%) of 115 underwent pancreaticoduodenectomy; and vascular reconstruction was performed in 51 (44%). A margin negative resection was achieved in 111 (97%) of 115 patients, and 83 (72%) were node negative. Median overall survival for all 185 patients was 20 months; 31 months for the 115 patients who completed all neoadjuvant therapy and surgery as compared to 13 months for the 70 patients who were not resected (P < .0001). CONCLUSION: After neoadjuvant therapy, surgical resection was performed in 62% of patients with borderline resectable pancreatic cancer. Those who normalized preoperative serum carbohydrate antigen 19-9 and had node negative pathology achieved the longest survival. To further improve median survival for all patients, we are incorporating adaptive approaches to neoadjuvant therapy sequencing based on objective assessments of response.


Assuntos
Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/terapia , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada , Comorbidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento
15.
World J Gastroenterol ; 25(21): 2623-2635, 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31210714

RESUMO

BACKGROUND: Laparoscopic resection of the pancreatic body and tail is the predominant methodology to remove lesions in these locations; its safety and surgical planning are relatively mature, but it remains a complex and high-precision surgical operation, requiring abundant experience and skills in laparoscopic surgery, with a 10% rate of complications. AIM: To verify the feasibility and safety, as well as to examine the complications of endoscopic pancreatectomy and healing mechanisms of pancreatic wounds after endoscopic resection. METHODS: Transgastric endoscopic resections of varying sizes of pancreases were performed in 15 healthy Bama miniature pigs. The technical success rate, the incidence of serious complications, and the survival of the animals were studied. The healing of the wounds was evaluated by sacrificing the animals at various time points. Finally, the expression of transforming growth factor-ß1 and Smad3/Smad7 in the surgical site was examined by immunohistochemistry to explore the role of these factors in wound healing of the pancreas. RESULTS: Partial and total resections were successfully performed in two groups of animals, respectively. The technical success rate and the survival rate of the pigs were both 100%. We obtained 12 pancreatic tissue samples by endoscopic resection. The pancreatic wounds were closed with metal clips in one group and the wounds healed well by forming scars. There was a small amount of pancreatic leakage in the other group, but it can be fully encapsulated. The level of transforming growth factor-ß1 (TGF-ß1) in the wounds increased during the inflammatory and fibrous hyperplasia phases, and decreased in the scar phase. The expression of Smad3 paralleled that of TGF-ß1, while the expression of Smad7 had an inverse relationship with the expression of TGF-ß1. CONCLUSION: Purely transgastric endoscopic resection of the pancreas is a safe, effective, and feasible procedure, but the incidence of pancreatic leakage in total pancreatic tail resection is high. The expression of TGF-ß1 and Smad3/Samd7 is related to the progression of pancreatic wound healing.


Assuntos
Endoscopia/métodos , Pâncreas/patologia , Pancreatectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Cicatrização/fisiologia , Animais , Modelos Animais de Doenças , Endoscopia/efeitos adversos , Estudos de Viabilidade , Humanos , Hiperplasia/etiologia , Hiperplasia/patologia , Incidência , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Proteína Smad3/metabolismo , Proteína Smad7/metabolismo , Taxa de Sobrevida , Suínos , Porco Miniatura , Fator de Crescimento Transformador beta/metabolismo
16.
Cir Esp ; 97(7): 377-384, 2019.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31164217

RESUMO

INTRODUCTION: Total pancreatectomy (TP) is an uncommon operation, with indications that have not been clearly defined and non-standardized postoperative results. We present a national multicentric study on TP and a comparison with the existing literature METHODS: A prospective observational study using data from the national registry of patients after pancreaticoduodenectomy and TP performed for any indication during the study period: January 1 to December 31, 2015 RESULTS: 1016 patients were included from 73 hospitals, 112 of whom had undergone TP. The percentage of TP from the total number of cases was 11%. The mean age was 63.5 years, and 57.2% were males. The most frequently suspected radiological diagnosis was pancreatic cancer (58/112 cases). The most common TP technique was "mesentery artery first" (43/112 cases). Venous resections were performed in 23 patients (20.5%). The percentage of postoperative complications within 90 days was 50%, but major complications (>IIIA) were only 20.7%. The overall 90-day mortality was 8% (9 patients). The average stay was 20.7 days. The 3most frequent definitive histological diagnoses were: adenocarcinoma of the pancreas, intraductal papillary mucinous neoplasm and chronic pancreatitis. The R0 rate was 67.8%. CONCLUSIONS: This study shows that the morbidity and mortality results of TP in Spain are similar or superior to previous publications. More precise TP studies are necessary, focused on specific complications such as endocrine insufficiency.


Assuntos
Pancreatectomia/métodos , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/epidemiologia , Adenocarcinoma/cirurgia , Idoso , Feminino , Humanos , Masculino , Artérias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Neoplasias Intraductais Pancreáticas/diagnóstico por imagem , Neoplasias Intraductais Pancreáticas/epidemiologia , Neoplasias Intraductais Pancreáticas/cirurgia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/cirurgia , Pancreatite Crônica/diagnóstico por imagem , Pancreatite Crônica/epidemiologia , Pancreatite Crônica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Sistema de Registros , Espanha/epidemiologia
17.
Surgery ; 166(2): 166-171, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31160061

RESUMO

BACKGROUND: Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. RESULTS: A total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54-0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30-0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32-0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (-$16,153, 95% CI: [-$23,342 to -$8,964]) centers. CONCLUSION: Patients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Custos de Cuidados de Saúde , Laparoscopia/economia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Laparoscopia/métodos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Análise de Regressão , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
18.
Pancreatology ; 19(5): 786-792, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31153781

RESUMO

BACKGROUND: Postoperative pancreatic fistula (POPF) is the most common complication after distal pancreatectomy (DP). In a recent RCT on pancreaticoduodenectomy (PD), perioperative hydrocortisone (HC) treatment reduced Clavien-Dindo (C-D) III-V complications. The aim of this study was to investigate whether perioperative HC treatment reduces the overall complications and clinically significant POPF after distal pancreatectomy (DP). METHODS: Fourty consecutive patients undergoing DP were randomized to receive intravenous HC 100mg/placebo every eight hours until the second postoperative day. Thirty-one patients were completed with DP and received HC/placebo every 8 h for two days postoperatively. The primary endpoint was overall complications (C-D III-V) and the secondary endpoint was the development of clinically significant POPF. RESULTS: Pancreatic duct diameter, operative time and blood loss were similar in the groups. Ninety-day mortality was zero. With HC treatment the rates of C-D III-V complications tended to be lower compared to the placebo group (5.9% vs 21.4%, p = 0.034). The rate of grade B/C POPF was significantly reduced with HC treatment compared to the placebo group (5.9% vs. 42.9%, p = 0.028). CONCLUSION: Perioperative HC treatment may have a favourable effect on overall major complications after open DP. HC treatment reduces the incidence of clinically significant POPF after open DP.


Assuntos
Hidrocortisona/uso terapêutico , Pancreatectomia/efeitos adversos , Fístula Pancreática/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Determinação de Ponto Final , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pancreatectomia/mortalidade , Ductos Pancreáticos/patologia , Fístula Pancreática/mortalidade , Pancreaticoduodenectomia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Fatores de Risco
19.
Trials ; 20(1): 332, 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31174583

RESUMO

BACKGROUND: The placement of prophylactic intra-abdominal drains has been common practice in abdominal operations including pancreatic surgery. The PANDRA trial showed that the omission of drains following pancreatic head resection was non-inferior to intra-abdominal drainage in terms of postoperative reinterventions and superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications. The aim of the present PANDRA II trial is to evaluate the clinical outcome with versus without prophylactic drain placement after distal pancreatectomy. METHODS: The PANDRA II trial is a mono-center, randomized controlled, non-inferiority trial with two parallel study groups. In the control group at least one passive intra-abdominal drain is placed at the pancreatic resection margin. In the experimental group no drains are placed. The primary endpoint of this trial will be the Comprehensive Complication Index (CCI) measuring all postoperative complications within 90 days. Secondary endpoints are in-hospital mortality and morbidity, including the rates of postoperative pancreatic fistula, chyle leak, postpancreatectomy hemorrhage, delayed gastric emptying, reinterventions and reoperations, surgical site infection, and abdominal fascia dehiscence. Moreover, length of hospital stay, duration of intensive care unit stay, and the rate of readmission after discharge from hospital (up to day 90 after surgery) are assessed. We will need to analyze 252 patients to test the hypothesis that no drainage is non-inferior to drain placement in terms of the CCI (δ 7.5 points) in a one-sided t test with a one-sided level of significance of 2.5% and a power of 80%. DISCUSSION: The results of the PANDRA II trial will help to evaluate the effect of an omission of prophylactic intraperitoneal drainage on the rate of complications after open or minimally invasive distal pancreatectomy. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS00013763 . Registered on 6 March 2018.


Assuntos
Drenagem/instrumentação , Pancreatectomia , Complicações Pós-Operatórias/prevenção & controle , Drenagem/efeitos adversos , Drenagem/mortalidade , Estudos de Equivalência como Asunto , Alemanha , Humanos , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
Trials ; 20(1): 356, 2019 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-31196166

RESUMO

BACKGROUND: Earlier nonrandomized studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss, and recovery. Only one randomized study has been conducted showing reduced time to functional recovery after LDP compared with ODP. METHODS: LAPOP is a prospective randomized, nonblinded, parallel-group, single-center superiority trial. Sixty patients with lesions in the pancreatic body or tail that are found by a multidisciplinary tumor board to need surgical resection will be randomized to receive LDP or ODP. The primary outcome variable is postoperative hospital stay, and secondary outcomes include functional recovery (defined as no need for intravenous medications or fluids and as the ability of an ambulatory patient to perform activities of daily life), perioperative bleeding, complications, need for pain medication, and quality of life comparison. DISCUSSION: The LAPOP trial will test the hypothesis that LDP reduces postoperative hospital stay compared with ODP. TRIAL REGISTRATION: ISRCTN, 26912858 . Registered on 28 September 2015.


Assuntos
Laparoscopia/métodos , Pancreatectomia/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos , Pancreatectomia/efeitos adversos , Estudos Prospectivos
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