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1.
Anticancer Res ; 41(11): 5703-5712, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34732443

RESUMO

BACKGROUND/AIM: In cases where neoadjuvant treatment (NAT) is administered, research on short-term postoperative outcomes appears to be insufficient. We compared short-term outcomes of upfront surgery (UpS) cases and NAT cases for pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: We retrospectively reviewed 1,228 cases that had elective pancreatectomy at Samsung Medical Center from 2010 to 2020. All cases were classified into resectable pancreatic cancer (RPC) and locally advanced pancreatic cancer (LAPC) according to NCCN guidelines 2017. In each group, factors were compared between the UpS and NAT groups. RESULTS: Rate of vascular resection was higher in the NAT group in RPC, compared to that in the NAT group in LAPC. Short-term postoperative outcomes had no significant differences between the UpS and NAT groups in both RPC and LAPC. CONCLUSION: In the NAT group, there were no significant differences from UpS in terms of short-term postoperative outcomes. Conversion surgery following NAT is a favorable strategy.


Assuntos
Carcinoma Ductal Pancreático/terapia , Terapia Neoadjuvante , Pancreatectomia , Neoplasias Pancreáticas/terapia , Pancreaticoduodenectomia , Idoso , Carcinoma Ductal Pancreático/diagnóstico por imagem , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Quimioterapia Adjuvante , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/mortalidade , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
2.
Medicine (Baltimore) ; 100(40): e27438, 2021 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-34622858

RESUMO

BACKGROUND: Vein resection pancreatoduodenectomy (VRPD) may be performed in selected pancreatic cancer patients. However, the main risks and benefits related to VRPD remain controversial. OBJECTIVE: This review aimed to evaluate the risks and survival benefits that the VRPD may add when compared with standard pancreatoduodenectomy (PD). METHODS: A systematic review and meta-analysis of studies comparing VRPD and PD were performed. RESULTS: VRPD was associated with a higher risk for postoperative mortality (risk difference: -0.01; 95% confidence interval [CI] -0.02 to -0.00) and complications (risk difference: -0.05; 95% CI -0.09 to -0.01) than PD. The length of hospital stay was not different between the groups (mean difference [MD]: -0.65; 95% CI -2.11 to 0.81). In the VRPD, the operating time was 69 minutes higher on average (MD: -69.09; 95% CI -88.4 to -49.78), with a higher blood loss rate (MD: -314.04; 95% CI -423.86 to -195.22). In the overall survival evaluation, the hazard ratio for mortality during follow-up on the group of VRPD was higher compared to the PD group (hazard ratio: 1.13; 95% CI 1.03-1.23). CONCLUSION: VRPD is associated with a higher risk of short-term complications and mortality and a lower probability of survival than PD. Knowing the risks and potential benefits of surgery can help clinicians to properly manage pancreatic cancer patients with venous invasion. The decision for surgery with major venous resection should be shared with the patients after they are informed of the risks and prognosis.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Idoso , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Carcinoma Ductal Pancreático/mortalidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Duração da Cirurgia , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Veia Porta/cirurgia
3.
Anticancer Res ; 41(10): 5123-5130, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34593463

RESUMO

BACKGROUND/AIM: The impact of venous resections and reconstruction techniques on morbidity after surgery for pancreatic cancer (PDAC) remains controversial. PATIENTS AND METHODS: A total of 143 patients receiving pancreatoduodenectomy (PD) for PDAC between 2013 and 2018 were identified from a prospective database. Morbidity and mortality after PD with tangential resection versus end-to-end reconstruction were assessed. RESULTS: Fifty-two of 143 (36.4%) patients underwent PD with portal venous resection (PVR), which was associated with longer operation times [398 (standard error (SE) 12.01) vs. 306 (SE 13.09) min, p<0.001]. PVR was associated with longer intensive-care-unit stay (6.3 vs. 3.8 days, p=0.054); morbidity (Clavien-Dindo classification (CDC) grade IIIa-V 45.8% vs. 35.8%, p=0.279) and 30-day mortality (4.1% vs. 4.2%, p>0.99) were not different. Tangential venous resection was associated with similar CDC grade IIIa-IV (42.9% vs. 50.0%, p=0.781) and 30-day mortality rates (3.5% vs. 4.1%, p=0.538) as segmental resection and end-to-end venous reconstruction. CONCLUSION: Both tangential and segmental PVR appear feasible and can be safely performed to achieve negative resection margins.


Assuntos
Adenocarcinoma/cirurgia , Veias Mesentéricas/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Veia Porta/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/mortalidade , Procedimentos Cirúrgicos Vasculares/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Margens de Excisão , Veias Mesentéricas/patologia , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Veia Porta/patologia , Complicações Pós-Operatórias , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
4.
Surg Clin North Am ; 101(5): 865-874, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34537148

RESUMO

The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.


Assuntos
Pancreatopatias/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Humanos , Fístula Pancreática/etiologia , Fístula Pancreática/terapia , Pancreaticoduodenectomia/mortalidade
5.
Ann Surg ; 274(3): 459-466, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34132696

RESUMO

OBJECTIVE: This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA: FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS: Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS: Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS: Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.


Assuntos
Falha da Terapia de Resgate , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/mortalidade , Fatores Etários , Idoso , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , América do Norte/epidemiologia , Radiografia Intervencionista/estatística & dados numéricos , Sistema de Registros , Reoperação/estatística & dados numéricos , Fatores de Risco , Suécia/epidemiologia
6.
Lancet Gastroenterol Hepatol ; 6(6): 438-447, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33915091

RESUMO

BACKGROUND: The benefit and safety of laparoscopic pancreatoduodenectomy (LPD) for the treatment of pancreatic or periampullary tumours remain controversial. Studies have shown that the learning curve plays an important role in LPD, yet there are no randomised studies on LPD after the surgeons have surmounted the learning curve. The aim of this trial was to compare the outcomes of open pancreatoduodenectomy (OPD) with those of LPD, when performed by experienced surgeons. METHODS: In this multicentre, open-label, randomised controlled trial done in 14 Chinese medical centres, we recruited patients aged 18-75 years with a benign, premalignant, or malignant indication for pancreatoduodenectomy. Eligible patients were randomly assigned (1:1) to undergo either LPD or OPD. Randomisation was centralised via a computer-generated system that used a block size of four. The patients and surgeons were unmasked to study group, whereas the data collectors, outcome assessors, and data analysts were masked. LPD and OPD were performed by experienced surgeons who had already done at least 104 LPD operations. The primary outcome was the postoperative length of stay. The criteria for discharge were based on functional recovery, and analyses were done on a modified intention-to-treat basis (ie, including patients who had a pancreatoduodenectomy regardless of whether the operation was the one they were assigned to). This trial is registered with Clinicaltrials.gov, number NCT03138213. FINDINGS: Between May 18, 2018, and Dec 19, 2019, we assessed 762 patients for eligibility, of whom 656 were randomly assigned to either the LPD group (n=328) or the OPD group (n=328). 31 patients in each group were excluded and 80 patients crossed over (33 from LPD to OPD, 47 from OPD to LPD). In the modified intention-to-treat analysis (297 patients in the LPD group and 297 patients in the OPD group), the postoperative length of stay was significantly shorter for patients in the LPD group than for patients in the OPD group (median 15·0 days [95% CI 14·0-16·0] vs 16·0 days [15·0-17·0]; p=0·02). 90-day mortality was similar in both groups (five [2%] of 297 patients in the LPD group vs six [2%] of 297 in the OPD group, risk ratio [RR] 0·83 [95% CI 0·26-2·70]; p=0·76). The incidence rate of serious postoperative morbidities (Clavien-Dindo grade of at least 3) was not significantly different in the two groups (85 [29%] of 297 patients in the LPD group vs 69 [23%] of 297 patients in OPD group, RR 1·23 [95% CI 0·94-1·62]; p=0·13). The comprehensive complication index score was not significantly different between the two groups (median score 8·7 [IQR 0·0-26·2] vs 0·0 [0·0-20·9]; p=0·06). INTERPRETATION: In highly experienced hands, LPD is a safe and feasible procedure. It was associated with a shorter length of stay and similar short-term morbidity and mortality rates to OPD. Nonetheless, the clinical benefit of LPD compared with OPD was marginal despite extensive procedural expertise. Future research should focus on identifying the populations that will benefit from LPD. FUNDING: National Natural Science Foundation of China and Tongji Hospital, Huazhong University of Science and Technology, China.


Assuntos
Ampola Hepatopancreática/cirurgia , Laparoscopia/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Adulto , Idoso , Ampola Hepatopancreática/patologia , Estudos de Casos e Controles , China/epidemiologia , Feminino , Humanos , Laparoscopia/métodos , Laparoscopia/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/mortalidade , Alta do Paciente/tendências , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Cirurgiões/estatística & dados numéricos
7.
Surgery ; 169(6): 1446-1453, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33618857

RESUMO

BACKGROUND: Although postoperative pancreatic fistula (POPF) is a common and critical complication of pancreatoduodenectomy (PD), effective strategies to prevent POPF have not yet been completely developed. Because appropriate management of POPF is important to reduce the mortality rate after PD, in this study we aimed to evaluate our approach for the management of POPF after PD, including the postoperative course. METHODS: This retrospective study included 605 consecutive patients who underwent PD at our hospital between 2010 and 2020. All patients who developed POPF were first managed conservatively, with drainage tubes placed during surgery retained to manage POPF. In cases wherein conservative treatment was unsuccessful, open drainage, followed by continuous negative pressure and continuous irrigation, was used. For open drainage, the surgical wound was opened bluntly (approximate length, 5 cm) under local anesthesia, and the fluid was directly and completely drained. RESULTS: The prevalence of POPF of grades B and C was 15.4% (n = 93) and 0.33% (n = 2), respectively. Of these patients, 1 required reoperation, 43 recovered with conservative management only, 47 required open drainage, and 4 required image-guided percutaneous drainage. Postoperative hemorrhage with a pseudoaneurysm was identified in 3 (0.66%) patients. The postoperative in-hospital mortality rate was low (n = 1, 0.16%). The rate of successful POPF management was 98.9%. CONCLUSION: Based on our high success rate in POPF management, we consider open drainage to be a safe primary management method for POPF.


Assuntos
Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Drenagem/métodos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/mortalidade , Fístula Pancreática/cirurgia , Pancreaticoduodenectomia/mortalidade , Hemorragia Pós-Operatória/etiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Adulto Jovem
8.
J Am Coll Surg ; 232(6): 864-871, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33640522

RESUMO

BACKGROUND: The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs). STUDY DESIGN: The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations. RESULTS: Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p < 0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival. CONCLUSIONS: LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/métodos , Hospitais com Baixo Volume de Atendimentos , Neoplasias Hepáticas/cirurgia , Idoso , Carcinoma Hepatocelular/mortalidade , Colecistectomia/mortalidade , Feminino , Hepatectomia/mortalidade , Humanos , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Pancreatectomia/mortalidade , Pancreaticoduodenectomia/mortalidade
9.
Surgery ; 169(6): 1427-1433, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33487433

RESUMO

BACKGROUND: Whether laparoscopic pancreatoduodenectomy is a feasible treatment option equivalent to open pancreatoduodenectomy remains unclear. Using a nationwide inpatient database, we investigated the postoperative outcomes of laparoscopic pancreatoduodenectomy versus open pancreatoduodenectomy. METHODS: We conducted a retrospective cohort study using a nationwide inpatient database in Japan. We included patients who underwent pancreatoduodenectomy from April 2016 to March 2018. One-to-four propensity score matching was used to compare in-hospital mortality, postoperative complications, perioperative findings, and total hospitalization costs between the 2 groups. We also compared outcomes between laparoscopic pancreatoduodenectomy and open pancreatoduodenectomy in low- and high-volume hospitals. RESULTS: We identified 2,100 eligible patients. The laparoscopic pancreatoduodenectomy group contained higher proportions of younger patients and patients with fewer comorbidities compared with the open pancreatoduodenectomy group. Using propensity score matching, 95 patients in the laparoscopic pancreatoduodenectomy group were matched with 380 patients in the open pancreatoduodenectomy group. No significant differences in in-hospital mortality or postoperative complication rates were found between the groups. Compared with the open pancreatoduodenectomy group, the laparoscopic pancreatoduodenectomy group showed a longer duration of anesthesia (639 vs 497 minutes; P < .001), higher proportion of unplanned mechanical ventilation (10% vs 3%; P = .007), and higher total hospitalization costs (32,242 vs 24,657 US dollars; P < .001). The subgroup analyses showed that laparoscopic pancreatoduodenectomy was associated with a higher proportion of unplanned mechanical ventilation than open pancreatoduodenectomy but only in low-volume hospitals. CONCLUSION: This study demonstrated almost no advantage of laparoscopic pancreatoduodenectomy over open pancreatoduodenectomy. Our results suggest that laparoscopic pancreatoduodenectomy can be an alternative option for open pancreatoduodenectomy only in high-volume hospitals.


Assuntos
Laparoscopia/métodos , Pancreaticoduodenectomia/métodos , Idoso , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/mortalidade , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Pontuação de Propensão , Estudos Retrospectivos , Resultado do Tratamento
10.
J Surg Oncol ; 123(2): 416-424, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33125737

RESUMO

BACKGROUND: Periampullary neuroendocrine tumors (NETs) arise from the duodenum, ampulla, and periampullary pancreas. Duodenal and ampullary NETs are rare and may have distinct biologic behavior from pancreatic NETs (P-NETs). We examined the outcomes of these entities. METHODS: An institutional database was queried for patients undergoing resection for pancreatic head, duodenal, or ampullary NETs from 2000 to 2018. Patients with MEN1 syndrome or follow up less than 12 months were excluded. RESULTS: Three hundred and ten patients were identified. Tumor locations were ampulla (n = 15), duodenum (n = 35) and pancreas (n = 260). Median follow-up and recurrence-free survival (RFS) were 60.9 (interquartile range [IQR]: 34.8-99.3) and 171.7 (IQR: 84.0-NR) months. Clinicopathologic data and survival outcomes were similar for duodenal and ampullary NETs (RFS: p = .347 and overall survival [OS]: p = .246) and were combined into an intestinal subtype (IS) group. There were no differences in OS or RFS when comparing IS-NET and P-NET. On multivariate analysis, tissue of origin was not associated with risk of recurrence. The current American Joint Committee on Cancer staging guidelines, which account for origin tissue, were predictive of outcomes for all subtypes. CONCLUSION: Tissue of origin does not appear to impact long-term outcomes when comparing IS-NETs and P-NETs. The AJCC staging system offers good discriminatory capacity in the context of the tissue type.


Assuntos
Ampola Hepatopancreática/cirurgia , Neoplasias do Ducto Colédoco/mortalidade , Neoplasias Duodenais/mortalidade , Recidiva Local de Neoplasia/mortalidade , Tumores Neuroendócrinos/mortalidade , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/patologia , Neoplasias do Ducto Colédoco/patologia , Neoplasias do Ducto Colédoco/cirurgia , Neoplasias Duodenais/patologia , Neoplasias Duodenais/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Estadiamento de Neoplasias , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/cirurgia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Estudos Prospectivos , Taxa de Sobrevida , Carga Tumoral
11.
Surg Endosc ; 35(5): 2273-2285, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32632485

RESUMO

BACKGROUND: The outcomes of minimally invasive pancreaticoduodenectomy have not been adequately compared with those of open pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma. We performed a meta-analysis to compare the perioperative and oncological outcomes of these two pancreaticoduodenectomy procedures specifically in patients with pancreatic ductal adenocarcinoma. METHODS: Before this study was initiated, a specific protocol was designed and has been registered in PROSEPRO (ID: CRD42020149438). Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, PubMed, EMBASE, Web of Science, Cochrane Central Register, and ClinicalTrials.gov databases were systematically searched for studies published between January 1994 and October 2019. Overall survival, disease-free survival, and time to commencing adjuvant chemotherapy were the primary endpoint measurements, whereas perioperative and short-term outcomes were the secondary endpoints. RESULTS: The final analysis included 9 retrospective cohorts comprising 11,242 patients (1377 who underwent minimally invasive pancreaticoduodenectomy and 9865 who underwent open pancreaticoduodenectomy). There were no significant differences in the patients' overall survival, operative time, postoperative complications, 30-day mortality, rate of vein resection, number of harvested lymph nodes, or rate of positive lymph nodes between the two approaches. However, disease-free survival, time to starting adjuvant chemotherapy, length of hospital stay, and rate of negative margins in patients who underwent minimally invasive pancreaticoduodenectomy showed improvements relative to those in patients who underwent open surgery. CONCLUSIONS: Minimally invasive pancreaticoduodenectomy provides similar or even improved perioperative, short-term, and long-term oncological outcomes when compared with open pancreaticoduodenectomy for patients with pancreatic ductal adenocarcinoma.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/etiologia , Idoso , Carcinoma Ductal Pancreático/mortalidade , Intervalo Livre de Doença , Humanos , Tempo de Internação , Duração da Cirurgia , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Estudos Retrospectivos , Resultado do Tratamento
12.
Surgery ; 169(5): 1093-1101, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33357999

RESUMO

BACKGROUND: The role of portal vein resection for pancreatic cancer is well established but not for pancreatic neuroendocrine neoplasms. Evidence from studies providing information on long-term outcome after venous resection in pancreatic neuroendocrine neoplasms patients is lacking. METHODS: This is a multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection with standard pancreaticoduodenectomy in patients with pancreatic neuroendocrine neoplasms. The primary endpoint was to evaluate the long-term survival in both groups. Progression-free survival and overall survival were calculated using the method of Kaplan and Meier, but a propensity score-matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. The secondary outcome was Clavien-Dindo ≥3. RESULTS: Sixty-one (11%) patients underwent pancreaticoduodenectomy with vein resection and 480 patients pancreaticoduodenectomy. Five (1%) perioperative deaths were recorded in the pancreaticoduodenectomy group, and postoperative clinically relevant morbidity rates were similar in the 2 groups (pancreaticoduodenectomy with vein resection 48% vs pancreaticoduodenectomy 33%). In the initial survival analysis, pancreaticoduodenectomy with vein resection was associated with worse 3-year progression-free survival (48% pancreaticoduodenectomy with vein resection vs 83% pancreaticoduodenectomy; P < .01) and 5-year overall survival (67% pancreaticoduodenectomy with vein resection vs 91% pancreaticoduodenectomy). After propensity score matching, no significant difference was found in both 3-year progression-free survival (49% pancreaticoduodenectomy with vein resection vs 59% pancreaticoduodenectomy; P = .14) and 5-year overall survival (71% pancreaticoduodenectomy with vein resection vs 69% pancreaticoduodenectomy; P = .98). CONCLUSION: This study demonstrates no significant difference in perioperative risk with a similar overall survival between pancreaticoduodenectomy and pancreaticoduodenectomy with vein resection. Tumor involvement of the superior mesenteric/portal vein axis should not preclude surgical resection in patients with locally advanced pancreatic neuroendocrine neoplasms.


Assuntos
Tumores Neuroendócrinos/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Veia Porta/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/mortalidade , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/mortalidade , Estudos Retrospectivos , Adulto Jovem
13.
Eur J Cancer ; 144: 81-90, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33341449

RESUMO

BACKGROUND: The incidence of periampullary cancer in the elderly is increasing. Safety and oncologic effectiveness of pancreaticoduodenectomy in elderly patients is still controversial. MATERIALS AND METHODS: From 2002 to 2016, patients with periampullary cancer were evaluated. Customised health information data provided by the National Health Insurance Corporation (NHIS-2018-1-157) were used for analysis. Chronological changes in the incidence of periampullary cancer and long-term survival outcomes were estimated according to patients' age. RESULT: A total of 148,080 patients were found to have periampullary cancer. Chronologically, the incidence of periampullary cancer increased, and the proportion of elderly patients with periampullary cancer prominently increased (about 2.1 times in patients in their 70s and about 4.7 times in those older than 80 years). The number of patients with pylorus-preserving pancreaticoduodenectomy in their 70s (about 5.6 times, p < 0.001) and over 80 years of age (about 8.9 times, p < 0.001) was much higher than the number of patients aged younger than 50 years (about 1.7 times) and in their 60s (about 2.5 times). Long-term survival was different as per diagnosis (p < 0.001). In addition, it was observed that age was a factor attenuating the survival of patients with resected periampullary cancers (p < 0.001). However, in case of patients older than 80 years, those who underwent surgical treatment showed a higher survival rate than those who did not undergo surgical treatment. CONCLUSION: We can recommend surgical treatment for elderly patients with resectable periampullary cancer. The survival data in this study can be useful references especially in making treatment plan for octogenarians diagnosed with periampullary cancer.


Assuntos
Ampola Hepatopancreática/cirurgia , Neoplasias do Ducto Colédoco/cirurgia , Bases de Dados Factuais/estatística & dados numéricos , Pancreaticoduodenectomia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/patologia , Neoplasias do Ducto Colédoco/epidemiologia , Neoplasias do Ducto Colédoco/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , República da Coreia/epidemiologia , Taxa de Sobrevida
14.
PLoS One ; 15(12): e0243515, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33270774

RESUMO

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.


Assuntos
Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Tomografia Computadorizada por Raios X/efeitos adversos , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Ductos Pancreáticos/patologia , Fístula Pancreática/diagnóstico , Fístula Pancreática/fisiopatologia , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/mortalidade , Pancreatite/etiologia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
15.
J Surg Oncol ; 122(6): 1132-1144, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33124067

RESUMO

BACKGROUND: Duodenal cancer is the second most common cause of cancer death in familial adenomatous polyposis (FAP) patients. In this study, we compare oncologic outcomes between sporadic and FAP-associated duodenal cancer. METHODS: In this retrospective study, all patients who underwent surgeries between 2000 and 2014 for either sporadic or FAP duodenal cancer were identified. The patients were grouped based on diagnoses and perioperative and survival outcomes were compared. RESULTS: A total of 56 patients with duodenal cancer (43 sporadic, 13 FAP) who underwent surgery were identified. Pancreatoduodenectomy (PD) was the most common procedure performed. The overall median survival was 7.5 years (1 year: 92%; 5 years: 58.1%). FAP patients had earlier tumor, node, and metastasis stage, less margin involvement, less perineural, and angiolymphatic invasion but had a comparable survival to sporadic patients. The median survival for FAP duodenal cancer was 7.4 vs 9.6 years for sporadic (P = .97) with similar utilization of adjuvant chemotherapy. Although not statistically significant, PD had an improved median survival compared to segmental duodenal resection (SDR) (9.6 years for PD vs 3.6 years for SDR, P = .17). Non-periampullary location and presence of positive lymph nodes were significant predictors of mortality on multivariate analysis. CONCLUSIONS: FAP duodenal cancer has no survival advantage compared to sporadic duodenal cancer despite an improved stage of resection with extraampullary lesions having a worse survival.


Assuntos
Adenocarcinoma/mortalidade , Polipose Adenomatosa do Colo/mortalidade , Neoplasias Duodenais/mortalidade , Pancreaticoduodenectomia/mortalidade , Adenocarcinoma/complicações , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Polipose Adenomatosa do Colo/complicações , Polipose Adenomatosa do Colo/patologia , Polipose Adenomatosa do Colo/cirurgia , Adulto , Idoso , Gerenciamento Clínico , Neoplasias Duodenais/complicações , Neoplasias Duodenais/patologia , Neoplasias Duodenais/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
16.
Pancreatology ; 20(7): 1540-1549, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32943343

RESUMO

BACKGROUND: Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture. PATIENTS AND METHOD: We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni- and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values. RESULTS: Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1-51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p = 0.004), prolonged operation time (Cutoff ˃610 min, p = 0.026) and postoperative pancreatic fistula (POPF) (p = 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p = 0.043) was a significant risk factor for death related to pseudoaneurysm. CONCLUSION: Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.


Assuntos
Falso Aneurisma/epidemiologia , Falso Aneurisma/etiologia , Duração da Cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/mortalidade , Aneurisma Roto/epidemiologia , Aneurisma Roto/mortalidade , Quimiorradioterapia Adjuvante , Criança , Embolização Terapêutica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/mortalidade , Hemorragia Pós-Operatória/mortalidade , Curva ROC , Radiologia Intervencionista , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
17.
BJS Open ; 4(5): 904-913, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32893988

RESUMO

BACKGROUND: Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher-volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume-outcome analysis of a complete national cohort in a health system with long-standing centralization. METHODS: Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high-volume (40 or more procedures/year) or medium-low-volume). RESULTS: Some 394 procedures were performed (201 in high-volume and 193 in medium-low-volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure-to-rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high-volume centre, medium-low-volume units had similar overall complication rates, lower 90-day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure-to-rescue rate. CONCLUSION: Centralization beyond medium volume will probably not improve on 90-day mortality or failure-to-rescue rates after pancreatoduodenectomy.


Assuntos
Fístula Pancreática/epidemiologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Idoso , Institutos de Câncer/organização & administração , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Noruega/epidemiologia , Neoplasias Pancreáticas/mortalidade , Sistema de Registros , Centros Cirúrgicos/organização & administração , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
18.
BJS Open ; 4(5): 884-892, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32841533

RESUMO

BACKGROUND: Dutch guidelines indicate that treatment of pancreatic head and periampullary malignancies should be started within 3 weeks of the multidisciplinary team (MDT) meeting. This study aimed to assess the impact of time to surgery on oncological outcomes. METHODS: This was a retrospective population-based cohort study of patients with pancreatic head and periampullary malignancies included in the Netherlands Cancer Registry. Patients scheduled for pancreatoduodenectomy and who were discussed in an MDT meeting from May 2012 to December 2016 were eligible. Time to surgery was defined as days between the final preoperative MDT meeting and surgery, categorized in tertiles (short interval, 18 days or less; intermediate, 19-32 days; long, 33 days or more). Oncological outcomes included overall survival, resection rate and R0 resection rate. RESULTS: A total of 2027 patients were included, of whom 677, 665 and 685 had a short, intermediate and long time interval to surgery respectively. Median time to surgery was 25 (i.q.r. 14-36) days. Longer time to surgery was not associated with overall survival (hazard ratio 0·99, 95 per cent c.i. 0·87 to 1·13; P = 0·929), resection rate (relative risk (RR) 0·96, 95 per cent c.i. 0·91 to 1·01; P = 0·091) or R0 resection rate (RR 1·01, 0·94 to 1·09; P = 0·733). Patients with pancreatic ductal adenocarcinoma and a long time interval had a lower resection rate (RR 0·92, 0·85 to 0·99; P = 0·029). DISCUSSION: A longer time interval between the last MDT meeting and pancreatoduodenectomy did not decrease overall survival.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Equipe de Assistência ao Paciente , Tempo para o Tratamento , Idoso , Carcinoma Ductal Pancreático/patologia , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Resultado do Tratamento
19.
BMC Surg ; 20(1): 140, 2020 Jun 22.
Artigo em Inglês | MEDLINE | ID: mdl-32571289

RESUMO

BACKGROUND: The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula. METHODS: Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group. RESULTS: From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05). CONCLUSIONS: Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.


Assuntos
Pâncreas/cirurgia , Pancreatopatias/cirurgia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/efeitos adversos , Estômago/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amilases/sangue , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/mortalidade , Drenagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ductos Pancreáticos/cirurgia , Fístula Pancreática/sangue , Fístula Pancreática/etiologia , Fístula Pancreática/mortalidade , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/mortalidade , Pancreaticojejunostomia/efeitos adversos , Pancreaticojejunostomia/métodos , Pancreaticojejunostomia/mortalidade , Estudos Retrospectivos , Irrigação Terapêutica , Adulto Jovem
20.
Sci Rep ; 10(1): 9621, 2020 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-32541683

RESUMO

To analyze the initial learning curve (LC) for robot-assisted pancreaticoduodenectomy (RAPD) and compare RAPD during the initial LC with open pancreaticoduodenectomy (OPD) in terms of outcome. This study is a retrospective review of patients who consecutively underwent RAPD and OPD between October 2015 and January 2020 in our hospital. 41 consecutive RAPD cases and 53 consecutive open cases were enrolled for review. Compared with OPD, RAPD required a significantly longer operative time (401.1 ± 127.5 vs. 230.8 ± 44.5 min, P < 0.001) and higher cost (194621 ± 78342 vs. 121874 ± 39973 CNY, P < 0.001). Moreover, compared with the OPD group, the RAPD group revealed a significantly smaller mean number of lymph nodes harvested in malignant cases (15.6 ± 5.9 vs 18.9 ± 7.3, P = 0.025). No statistically significant differences were observed between the two groups in terms of incidence of Clavien-Dindo grade III-V morbidities and 90-day mortality and readmission (P>0.05). In the CUSUM graph, one peak point was observed at the 8th case, after which the operation time began to decrease. LC for RAPD may be less than 30 cases, and RAPD is safe and feasible during the initial LC.


Assuntos
Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Laparotomia , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/educação , Pancreaticoduodenectomia/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/mortalidade
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