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1.
Anticancer Res ; 41(10): 5223-5229, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34593475

RESUMO

AIM: The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. PATIENTS AND METHODS: We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. RESULTS: Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). CONCLUSION: AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.


Assuntos
Anastomose Cirúrgica/normas , Perda Sanguínea Cirúrgica/prevenção & controle , Hospitais com Alto Volume de Atendimentos/normas , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/normas , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
2.
Medicine (Baltimore) ; 100(35): e26918, 2021 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-34477122

RESUMO

BACKGROUND: Radical pancreaticoduodenectomy is the only possible cure for pancreatic head adenocarcinoma, and although several RCT studies have suggested the extent of lymph node dissection, this issue remains controversial. This article wanted to evaluate the survival benefit of different lymph node dissection extent for radical surgical treatment of pancreatic head adenocarcinoma. METHODS: A total of 240 patients were assessed for eligibility in the study, 212 of whom were randomly divided into standard lymphadenectomy group (SG) or extended lymphadenectomy group (EG), there were 97 patients in SG and 95 patients in EG receiving the radical pancreaticoduodenectomy. RESULT: The demography, histopathology and clinical characteristics were similar between the 2 groups. The 2-year overall survival rate in the SG was higher than the EG (39.5% vs 25.3%; P = .034). The 2-year overall survival rate in the SG who received postoperative adjuvant chemotherapy was higher than the EG (60.7% vs 37.1%; P = .021). There was no significant difference in the overall incidence of complications between the 2 groups (P = .502). The overall recurrence rate in the SG and EG (70.7% vs 77.5%; P = .349), and the patterns of recurrence between 2 groups were no significant differences. CONCLUSION: In multimodality therapy system, the efficacy of chemotherapy should be based on the appropriate lymphadenectomy extent, and the standard extent of lymphadenectomy is optimal for resectable pancreatic head adenocarcinoma. The postoperative slowing of peripheral blood lymphocyte recovery might be 1 of the reasons why extended lymphadenectomy did not result in survival benefits. CLINICAL TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT02928081) in October 7, 2016. https://clinicaltrials.gov/.


Assuntos
Adenoma/cirurgia , Excisão de Linfonodo/normas , Neoplasias Pancreáticas/cirurgia , Adenoma/epidemiologia , Adenoma/mortalidade , Idoso , Distribuição de Qui-Quadrado , Feminino , Humanos , Excisão de Linfonodo/métodos , Excisão de Linfonodo/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Pancreaticoduodenectomia/estatística & dados numéricos , Modelos de Riscos Proporcionais , Estudos Prospectivos , Método Simples-Cego
3.
PLoS One ; 16(3): e0248633, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33735191

RESUMO

Factors for overall survival after pancreatic ductal adenocarcinoma (PDAC) seem to be nodal status, chemotherapy administration, UICC staging, and resection margin. However, there is no consensus on the definition for tumor free resection margin. Therefore, univariate OS as well as multivariate long-term survival using cancer center data was analyzed with regards to two different resection margin definitions. Ninety-five patients met inclusion criteria (pancreatic head PDAC, R0/R1, no 30 days mortality). OS was analyzed in univariate analysis with respect to R-status, CRM (circumferential resection margin; positive: ≤1mm; negative: >1mm), nodal status, and chemotherapy administration. Long-term survival >36 months was modelled using multivariate logistic regression instead of Cox regression because the distribution function of the dependent data violated the requirements for the application of this test. Significant differences in OS were found regarding the R status (Median OS and 95%CI for R0: 29.8 months, 22.3-37.4; R1: 15.9 months, 9.2-22.7; p = 0.005), nodal status (pN0 = 34.7, 10.4-59.0; pN1 = 17.1, 11.5-22.8; p = 0.003), and chemotherapy (with CTx: 26.7, 20.4-33.0; without CTx: 9.7, 5.2-14.1; p < .001). OS according to CRM status differed on a clinically relevant level by about 12 months (CRM positive: 17.2 months, 11.5-23.0; CRM negative: 29.8 months, 18.6-41.1; p = 0.126). A multivariate model containing chemotherapy, nodal status, and CRM explained long-term survival (p = 0.008; correct prediction >70%). Chemotherapy, nodal status and resection margin according to UICC R status are univariate factors for OS after PDAC. In contrast, long-term survival seems to depend on wider resection margins than those used in UICC R classification. Therefore, standardized histopathological reporting (including resection margin size) should be agreed upon.


Assuntos
Carcinoma Ductal Pancreático/terapia , Pâncreas/patologia , Neoplasias Pancreáticas/terapia , Pancreaticoduodenectomia/estatística & dados numéricos , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Carcinoma Ductal Pancreático/diagnóstico , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Quimioterapia Adjuvante/métodos , Quimioterapia Adjuvante/estatística & dados numéricos , Feminino , Fluoruracila/administração & dosagem , Seguimentos , Humanos , Irinotecano/administração & dosagem , Estimativa de Kaplan-Meier , Leucovorina/administração & dosagem , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/estatística & dados numéricos , Estadiamento de Neoplasias , Oxaliplatina/administração & dosagem , Pâncreas/cirurgia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/normas , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/normas , Medição de Risco/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
4.
Am Surg ; 87(3): 396-403, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32993353

RESUMO

BACKGROUND: The mainstay of treatment for pancreatic cancer is surgical resection; however, positive surgical margins remain commonplace. We identified hospitals with higher than predicted rates of positive margins and isolated factors that caused this discordance. METHODS: This is a retrospective review of patients with head of the pancreas adenocarcinoma in the National Cancer Database between 2004 and 2015. A nomogram was used to calculate the observed to expected positive margin rates (O/E) for facilities. If the O/E differed significantly (P < .05), it was considered an outlier. RESULTS: Among a total of 19 968 patients, 24.3% had positive margins. Among hospitals with lower than expected positive margin rates, 73.6% were academic or research programs, 17% were comprehensive community cancer programs, and none were community cancer programs (P = .0002). Within the group with higher than expected positive margin rates, 47% were comprehensive community cancer programs and 38.6% were academic or research programs (P = .0002). The mean hospital volume was higher in the low positive margin group (110.4 vs 48.8, P < .0001). CONCLUSIONS: Facility type and hospital volume can predict improvement in the O/E ratio for margin positivity in pancreatic adenocarcinoma resection. Surgeons should consider referral to academic or research facilities with higher case volumes for improved surgical resection.


Assuntos
Adenocarcinoma/cirurgia , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Baixo Volume de Atendimentos/normas , Margens de Excisão , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/normas , Melhoria de Qualidade , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nomogramas , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Garantia da Qualidade dos Cuidados de Saúde , Estudos Retrospectivos , Análise de Sobrevida , Estados Unidos/epidemiologia
5.
Sichuan Da Xue Xue Bao Yi Xue Ban ; 51(4): 462-466, 2020 Jul.
Artigo em Chinês | MEDLINE | ID: mdl-32691551

RESUMO

Objective: To explore the clinical efficacy of pancreaticoduodenectomy (PD) combined with vascular resection and reconstruction under robotic surgery system in the treatment of borderline resectable pancreatic cancer. Methods: The clinical data of 17 patients with borderline resectable pancreatic cancer who underwent PD combined with vascular resection and reconstruction (see the Video 1 in Supplemental Contents, http://ykxb.scu.edu.cn/article/doi/10.12182/20200760202) under robotic surgery system between August 2011 and September 2018 was analyzed retrospectively. Results: There were 4 cases required conversion because of serious tumor invasion and soft pancreas texture, the other 13 cases were successfully completed. 16 cases (94%) achieved margin-negative resection (R0 resection), 14 cases combined with vein resection, and 3 cases combined with arterial resection. The mean operation time was (401±170) min, the mean blood loss was (647±345) mL, the mean postoperative length of hospital stay was (20±8) d. There was no perioperative death. Postoperative pathology findings and follow-up outcomes were as follows: 1 patient was diagnosed as intraductal papillary mucinous neoplasm (IPMN) and 1 patient was diagnosed as pancreatic neuroendocrine tumors (PNET) (Grade 1), 8 patients with pancreatic ductal adenocarcinoma (PDAC). 1 patient with pancreatic neuroendocrine carcinoma (PNEC) died because of tumor recurrence and metastasis during the follow-up period, the median (Min-Max) survival time was 12 (8-26) months. 5 patients with PDAC and 1 patient with malignant IPMN were currently in the follow-up period. Conclusion: It is safe and feasible to perform RPD with vascular resection and reconstruction. The patient's condition should be fully evaluated before surgery to select the most appropriate treatment.


Assuntos
Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Pancreaticoduodenectomia , Procedimentos Cirúrgicos Robóticos , Carcinoma Ductal Pancreático/cirurgia , Humanos , Recidiva Local de Neoplasia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/normas , Resultado do Tratamento
6.
Medicine (Baltimore) ; 99(21): e20403, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32481341

RESUMO

Hepatic artery variations increase the difficulty of laparoscopic pancreaticoduodenectomy (LPD). The safety and efficacy of LPD in the presence of aberrant hepatic arteries (AHA) must be further verified.Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. Variation type, intraoperative management, and clinical treatment outcomes were compared.There were 54 cases (24.8%) of AHA. The most common hepatic artery variation was accessory right hepatic artery (RHA) from the superior mesenteric artery (SMA, n = 12, 5.5%), followed by replaced RHA from the SMA (n = 10, 4.6%), accessory left hepatic artery from the SMA (n = 10, 4.6%), and replaced common hepatic artery from the SMA (n = 6, 2.8%). Each type of arterial variation was successfully preserved in all cases, and there were no significant effects on the evaluated surgical indices, conversion rate, incidence of postoperative complications, or follow-up results.Our findings indicated that preservation of AHAs during total LPD is feasible. There were no significant effects on surgical indices, incidence of postoperative complications, or follow-up outcomes.The influence of AHA on the safety and efficacy of LPD must be further verified. Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. There were 54 cases (24.8%) of AHA. There were no significant effects of AHAs on surgical indices, incidence of postoperative complications, or follow-up outcomes.


Assuntos
Angiografia/estatística & dados numéricos , Artéria Hepática/anormalidades , Pancreaticoduodenectomia/estatística & dados numéricos , Idoso , Angiografia/métodos , Feminino , Artéria Hepática/fisiopatologia , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Estudos Retrospectivos
7.
World J Surg ; 44(8): 2761-2769, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32270224

RESUMO

BACKGROUND: The first enhanced recovery after surgery (ERAS) guidelines for pancreatoduodenectomy (PD) were developed in 2012. The study aimed to assess compliance and outcomes of an ERAS protocol for PD, to study correlation between compliance and outcomes, and to identify risk factors for complications. METHODS: Retrospective cohort analysis is based on a prospective database, including all consecutive patients undergoing elective PD within an ERAS program in four centers: Lausanne University Hospital (Switzerland), Carolinas Medical Center (United States), Edouard Herriot Hospital (France), and University Medical Center Hamburg-Eppendorf (Germany). Patients' characteristics, postoperative outcome and ERAS compliance were assessed. Logistic regression analysis was performed to assess predictors of postoperative complications. RESULTS: Between October 2012 and June 2017, 404 consecutive patients underwent PD. Median length of stay was 14 days with 11.3% readmission rate. Mean overall compliance was 62%, with pre-, intra- and postoperative compliance of 93%, 80% and 30%, respectively. Overall compliance ≥ 70% versus < 70% was significantly associated with a reduction in complications (p = 0.029) and length of stay (p < 0.001). Avoidance of postoperative nasogastric tube (OR = 0.31, p = 0.043), mobilization on day of surgery (OR = 0.28, p = 0.043), and mobilization more than 6 h on postoperative day 2 (OR = 0.45, p = 0.001) were independent predictors of reduced overall complications. CONCLUSIONS: Implementation of enhanced recovery for PD is challenging, especially in the postoperative period. Overall compliance with ERAS protocol ≥ 70% was associated with decreased complications and length of stay. Specific ERAS elements, such as avoidance of postoperative nasogastric tube and early mobilization, independently improved outcomes.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Pancreatopatias/cirurgia , Pancreaticoduodenectomia , Idoso , Doenças do Sistema Digestório/cirurgia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/normas , Recuperação Pós-Cirúrgica Melhorada/normas , Europa (Continente) , Estudos de Viabilidade , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/normas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
8.
J Surg Oncol ; 121(6): 936-944, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32124437

RESUMO

BACKGROUND: Composite outcomes may more accurately reflect patient and provider expectations around optimal care. We sought to determine the impact of achieving a so-called "textbook oncologic outcome" (TOO) among patients undergoing resection of pancreatic adenocarcinoma (PDAC). METHODS: Patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2006 and 2016 were identified in the National Cancer Database (NCDB). TOO was defined by: margin negative resection, compliant lymph node evaluation, no prolonged length-of-stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Factors associated with TOO and overall survival (OS) were evaluated using multivariable logistic and Cox regression models, respectively. RESULTS: Among 18 608 patients who underwent PD at 782 hospitals, many patients successfully achieved certain TOO factors such as R0 margin (77.9%) and no 30-day mortality (96.9%), while other TOO criteria such as receipt of adjuvant therapy (48.2%) were achieved less frequently. Overall, only 3124 (16.8%) patients achieved a TOO. Factors associated with lower odds of TOO included: older age, Black race, Medicaid insurance, Community facility, and low PD facility (<20 PD/y) (all P < .05). Achievement of a TOO was associated with lower risk of mortality (HR 0.74; 95% CI, 0.70-0.77). CONCLUSIONS: While TOO was associated with improved long-term survival, TOO was only achieved in 16.8% of patients undergoing PD.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/estatística & dados numéricos , Idoso , Carcinoma Ductal Pancreático/mortalidade , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologia
9.
United European Gastroenterol J ; 8(3): 249-255, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32213017

RESUMO

Intraductal papillary mucinous neoplasms are common lesions with the potential of harbouring/developing a pancreatic cancer. An accurate evaluation of intraductal papillary mucinous neoplasms with high-resolution imaging techniques and endoscopic ultrasound is mandatory in order to identify patients worthy either of surgical treatment or surveillance. In this review, the diagnosis and management of patients with intraductal papillary mucinous neoplasms are discussed with a specific focus on current guidelines. Areas of uncertainty are also discussed, as there are controversies related to the optimal indications for surgery, surveillance protocols and surveillance discontinuation.


Assuntos
Carcinoma Ductal Pancreático/diagnóstico , Cisto Pancreático/diagnóstico , Ductos Pancreáticos/diagnóstico por imagem , Neoplasias Intraductais Pancreáticas/diagnóstico , Idoso , Doenças Assintomáticas/terapia , Carcinoma Ductal Pancreático/complicações , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/terapia , Colangiopancreatografia por Ressonância Magnética/normas , Imagem de Difusão por Ressonância Magnética/normas , Progressão da Doença , Endossonografia/normas , Gastroenterologia/métodos , Gastroenterologia/normas , Humanos , Achados Incidentais , Masculino , Oncologia/métodos , Oncologia/normas , Pancreatectomia/normas , Cisto Pancreático/etiologia , Cisto Pancreático/mortalidade , Cisto Pancreático/terapia , Ductos Pancreáticos/patologia , Ductos Pancreáticos/cirurgia , Neoplasias Intraductais Pancreáticas/complicações , Neoplasias Intraductais Pancreáticas/mortalidade , Neoplasias Intraductais Pancreáticas/terapia , Pancreaticoduodenectomia/normas , Guias de Prática Clínica como Assunto , Prognóstico , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Tomografia Computadorizada por Raios X/normas , Conduta Expectante/normas
10.
Scand J Surg ; 109(1): 29-33, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32192422

RESUMO

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy.


Assuntos
Pancreatopatias/cirurgia , Pancreaticoduodenectomia , Seleção de Pacientes , Procedimentos Cirúrgicos Robóticos , Competência Clínica/normas , Competência Clínica/estatística & dados numéricos , Educação/normas , Educação/estatística & dados numéricos , Educação de Pós-Graduação em Medicina/normas , Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Laparoscopia , Curva de Aprendizado , Procedimentos Cirúrgicos Minimamente Invasivos , Pancreaticoduodenectomia/educação , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Pancreaticoduodenectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/normas , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos , Resultado do Tratamento
11.
Scand J Surg ; 109(1): 4-10, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31969066

RESUMO

BACKGROUND AND AIMS: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. MATERIALS AND METHODS: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. RESULTS: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. CONCLUSION: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.


Assuntos
Hospitais com Alto Volume de Atendimentos , Pancreatectomia/normas , Neoplasias Pancreáticas , Pancreaticoduodenectomia/normas , Análise Custo-Benefício , Falha da Terapia de Resgate/economia , Falha da Terapia de Resgate/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/economia , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Pancreatectomia/efeitos adversos , Pancreatectomia/economia , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/economia , Pancreaticoduodenectomia/mortalidade , Prognóstico
12.
Surg Endosc ; 34(6): 2758-2762, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31953732

RESUMO

BACKGROUND: RPD (Robotic pancreatoduodenectomy) was first performed by P. C. Giulianotti in 2001 (Arch Surg 138(7):777-784, 2003). Since then, the complexity and lack of technique standardization has slowed down its widespread utilization. RPD has been increasingly adopted worldwide and in few centres is the preferred apporached approach by certain surgeons. Some large retrospective series are available and data seem to indicate that RPD is safe/feasible, and a valid alternative to the classic open Whipple. Our group has recently described a standardized 17 steps approach to RPD (Giulianotti et al. Surg Endosc 32(10): 4329-4336, 2018). Herin, we present an educational step-by-step surgical video with short technical/operative description to visually exemplify the RPD 17 steps technique. METHODS: The current project has been approved by our local Institutional Review Board (IRB). We edited a step-by-step video guidance of our RPD standardized technique. The data/video images were collected from a retrospective analysis of a prospectively collected database (IRB approved). The narration and the images describe hands-on operative "tips and tricks" to facilitate the learning/teaching/evaluation process. RESULTS: Each of the 17 surgical steps is visually represented and explained to help the in-depth understanding of the relevant surgical anatomy and the specific operative technique. CONCLUSIONS: Educational videos descriptions like the one herein presented are a valid learning/teaching tool to implement standardized surgical approaches. Standardization is a crucial component of the learning curve. This approach can create more objective and reproducible data which might be more reliably assessed/compared across institutions and by different surgeons. Promising results are arising from several centers about RPD. However, RPD as gold standard-approach is still a matter of debate. Randomized-controlled studies (RCT) are required to better validate the precise role of RPD.


Assuntos
Pancreaticoduodenectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educação , Chicago , Bases de Dados Factuais , Humanos , Curva de Aprendizado , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/normas
13.
World J Surg ; 44(8): 2784-2793, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31641837

RESUMO

BACKGROUND: Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS: 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS: Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION: Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.


Assuntos
Institutos de Câncer , Hospitais com Alto Volume de Atendimentos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Adulto , Idoso , Institutos de Câncer/normas , Institutos de Câncer/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Pâncreas/cirurgia , Neoplasias Pancreáticas/epidemiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Pancreaticoduodenectomia/normas , Pancreaticoduodenectomia/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Análise de Sobrevida
14.
Zhonghua Wai Ke Za Zhi ; 57(8): 572-577, 2019 Aug 01.
Artigo em Chinês | MEDLINE | ID: mdl-31422625

RESUMO

Objective: To examine the effect of standardized lymphectomy and sampling of resected lymph nodes (LN) on TNM staging of resectable pancreatic head cancer. Methods: Consecutive patients with resectable pancreatic head cancer who received standard pancreatoduodenctomy at Department of General Surgery in Beijing Hospital from December 2017 to November 2018 were recruited as study group. After operation, the surgeon sampled lymph nodes from the fresh specimen following the Japanese Gastric Cancer Guidelines.Thirty-three cases were recruited in the study group and the mean age was (59.8±15.2) years.Pathologic reports from December 2015 to November 2016 were taken as control group, containing 29 cases with age of (57.0±13.0) years. Number of lymph nodes, standard-reaching ratio and positive nodes ratio were compared between two groups. According to the seventh edition and eighth edition of TNM staging, the changes of N staging and TNM staging were analysed. The quantitative data conforming to normal distribution were tested by independent sample t test, the quantitative data not conforming to normal distribution were tested by rank sum test, and the enumeration data were analysed by χ(2) test. Results: The basal data of the two groups were comparable (all P>0.05) . The number of lymph nodes sampled in the study group was 23.27±8.87, significantly more than in control group (12.86±5.90, t=0.653, P=0.000) .Ratio of cases with more than 15 nodes was 81.8% (27/33) in the study group and 34.5% (10/29) in the control group with statistical significance (χ(2)=14.373, P=0.000) . In the study group, the positive lymph node ratios of No. 17a+17b, 14a+14b, 8a+8p LN were 36.4% (12/33) , 30.3% (10/33) and 9.1% (3/33) respectively. The positive lymph node ratio in No.14a+14b LN was higher than in No.8 LN (χ(2)=4.694, P=0.030) . According to the change in N staging system in the AJCC eighth edition, 2 cases (6.1%, 2/33) changed from ⅠB to ⅡA, 7 cases (21.2%, 7/33) from ⅡA to ⅠB and 5 cases (15.2%, 5/33) changed from ⅡB to Ⅲ (25.0%, 5/20) . Conclusions: No.14 LN should be treated as the first station rather than second station because of the anatomic character and higher metastatic ratio. Standardised lymphectomy and sampling may increase the number of LN resected and improve the TNM staging of resectable pancreatic head cancer.


Assuntos
Excisão de Linfonodo/normas , Linfonodos/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/normas , Adulto , Idoso , Humanos , Excisão de Linfonodo/métodos , Linfonodos/cirurgia , Metástase Linfática , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pancreaticoduodenectomia/métodos , Prognóstico
15.
BJS Open ; 3(3): 327-335, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31183449

RESUMO

Background: Whether the portal/superior mesenteric vein (PV) should be resected during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) based on preoperative CT or intraoperative findings is controversial. Methods: This was a retrospective study with data of patients who had undergone pancreatoduodenectomy for PDAC between 2002 and 2016 in a tertiary referral centre. Based on the extent of contact between the PV and tumour on CT, patients were categorized into: group 1, no contact; group 2, contact 180° or less; group 3, contact greater than 180°. Extent of pathological PV invasion (pPV) (no invasion, pv0; invasion to tunica adventitia, pv1; invasion to media, pv2; invasion to intima, pv3) was compared with patient survival. To assess the feasibility of performing PV resection (PVR) based on intraoperative findings, the prognosis of patients in groups 1 and 2 with pv0 and no PVR (PVR(-)pv0) was compared with that of patients who had PVR (PVR(+)pv0), selected using propensity score matching. Results: Groups 1, 2 and 3 comprised 230, 232 and 38 patients respectively, and PVR was performed in 10·9, 73·3 and 95 per cent of them (P < 0·001). Extent of pPV differed significantly (P < 0·001). The positive predictive value of radiological tumour contact with PV in predicting positive pPV was 42·6 per cent. In 64 patients with PVR(-)pv0 and 64 matched patients with PVR(+)pv0, the R0 resection rate (66 versus 73 per cent respectively; P = 0·337) and survival (median 32·4 versus 32·1 months; P = 0·780) were not significantly different. Conclusion: PVR is needed only when the tumour is in clear contact with the PV and cannot be detached during surgery.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Veias Mesentéricas/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Veia Porta/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/diagnóstico por imagem , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Estudos de Viabilidade , Feminino , Humanos , Período Intraoperatório , Japão/epidemiologia , Masculino , Veias Mesentéricas/patologia , Pessoa de Meia-Idade , Invasividade Neoplásica/diagnóstico por imagem , Invasividade Neoplásica/patologia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/normas , Veia Porta/diagnóstico por imagem , Veia Porta/patologia , Valor Preditivo dos Testes , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Centros de Atenção Terciária , Tomografia Computadorizada por Raios X/métodos
16.
Hepatobiliary Pancreat Dis Int ; 18(5): 478-483, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30846244

RESUMO

BACKGROUND: Pancreaticoduodenectomy is a challenging surgical intervention that remains the cornerstone in the treatment of localized peri­ampullary pathologies. The concept of treatment standardization has been well-established in many high-volume centers in the world. Here, we present our experience in pancreaticoduodenectomy from 1994 to 2015. METHODS: We performed a retrospective review of the medical charts of patients who underwent pancreaticoduodenectomy at our institution. Data was entered to SPSS statistical software and analyzed. The Mann-Whitney U and Fisher's exact tests were used to report statistical differences between groups. RESULTS: Of the 370 patients who underwent pacreaticoduodenectomy, 300 were analyzed. The 1-, 3-, 5- and 10-year survival rates were 85%, 35%, 15%, and 7%, respectively with a 30-day mortality rate of 5.0% (15 patients). The median age of the patients was 61 (13-84) years, with 193 (64.3%) males and 107 (35.7%) females. The median operative time was 300 (130-570) min. The median postoperative length of hospital stay was 12 (5-76) days. Thirty-two patients required re-laparotomies; 10 for pancreatic leak, 7 for biliary leak and 15 for control of bleeding. Seventy-five (25.0%) patients developed pancreatic fistulae. Delayed gastric emptying was present in 31 (10.3%) patients. A significant improvement in surgical outcome was observed in cases done after 2008 which indicates the important role of specialized team in surgical management. CONCLUSIONS: The number of patients undergoing pancreaticoduodenectomy has been increasing annually over the past twenty-two years in our institution with results comparable to published series from high-volume centers. Through standardization of surgical techniques and perioperative management carried out by a specialist team, our results continue to improve despite the increasing complexity of cases referred to our unit.


Assuntos
Ductos Biliares/cirurgia , Neoplasias do Sistema Digestório/cirurgia , Ductos Pancreáticos/cirurgia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/estatística & dados numéricos , Hemorragia Pós-Operatória/etiologia , Especialização/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Competência Clínica , Neoplasias do Sistema Digestório/patologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Oriente Médio , Estadiamento de Neoplasias , Duração da Cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/normas , Pancreaticoduodenectomia/tendências , Hemorragia Pós-Operatória/cirurgia , Padrões de Referência , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
17.
Br J Surg ; 106(6): 747-755, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30706456

RESUMO

BACKGROUND: Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation. METHODS: Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken. RESULTS: Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality. CONCLUSION: This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.


Assuntos
Auditoria Médica , Pancreaticoduodenectomia/normas , Padrões de Prática Médica/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Países Baixos , Avaliação de Resultados em Cuidados de Saúde , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/mortalidade , Pancreaticoduodenectomia/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Sistema de Registros
18.
J Surg Res ; 235: 453-458, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30691829

RESUMO

BACKGROUND: Assessment of optimal patient outcomes from health care delivery is critical for success amidst current reform. We developed a composite index of quality for pancreaticoduodenectomy (PD) and compared high and low performers nationwide. METHODS: We performed a retrospective analysis of 17,220 patients undergoing elective PD between October 2010 and June 2014 using the Vizient database. A quality index score (QIS) was developed from five variables associated with optimal outcomes: postoperative complication rate, length of stay, 30-d readmission rate, mortality rate, and hospital volume. Value was defined as hospital-based QIS divided by mean hospital charges. High-value centers (top quintile) were compared to low-value centers (bottom quintile). RESULTS: The majority of high-value centers (79%) achieved top performer status in 1-2 of five quality categories though only 11% were low performer in at least one category. Conversely, 41% of low-value centers were top performers in at least one category, although rarely more than one (8%); 63% of low-value centers were low performers in two or more categories. There was no significant association between QIS and hospital charges (-570, 95% CI -1308 to 168, P = 0.13). CONCLUSIONS: High-value centers infrequently provided high quality surgical care across all five metrics but instead excelled in a few quality metrics while avoiding low performance in any quality metric. Although low-value centers could achieve excellence in one quality metric, they were frequently low performers in two or more outcomes. Improvements in value of PD can be achieved by a consistent effort across all quality metrics rather than efforts at constraining financial expenditures of health care delivery.


Assuntos
Hospitais/estatística & dados numéricos , Pancreaticoduodenectomia/normas , Humanos , Pancreaticoduodenectomia/economia , Pancreaticoduodenectomia/estatística & dados numéricos , Estudos Retrospectivos
19.
Langenbecks Arch Surg ; 404(2): 159-165, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30397780

RESUMO

BACKGROUND: Pancreatic surgery has undergone substantial changes during the last decades. Improved surgical techniques and perioperative care have contributed to improved outcomes and allow safe surgery with mortality rates below 5% in specialized centers today. In parallel, surgical indications and procedures have been continuously extended especially with regard to pancreatic cancer surgery including vascular resections and multivisceral approaches for advanced findings. PURPOSE: With the growing awareness of the need to report outcomes scientifically, it has become obvious that only standardized definitions allow a reasonable description and comparability with regard to indications, procedures, and especially complications. Consequently, a number of efforts have been undertaken to achieve this aim, including basic nomenclatures, preoperative definition of resectability, and specific outcome parameters. CONCLUSION: This review gives an overview on the development of international standardizations in pancreatic surgery and the current status and discusses their scientific importance and the most important current controversies in the context of the present literature as well as the ongoing future approaches in this field.


Assuntos
Pancreatectomia/normas , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/normas , Guias de Prática Clínica como Assunto , Feminino , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Pancreatectomia/métodos , Pancreatectomia/mortalidade , Fístula Pancreática/prevenção & controle , Fístula Pancreática/cirurgia , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento
20.
PLoS One ; 13(12): e0209608, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30592736

RESUMO

INTRODUCTION: Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy. METHODS: We performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery. RESULTS: A total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)). CONCLUSIONS: Standardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.


Assuntos
Tempo de Internação , Pancreaticoduodenectomia , Alta do Paciente , Assistência Perioperatória , Adulto , Idoso , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/normas , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Estudos Retrospectivos , Fatores de Risco
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