Preoperative diabetes mellitus and long-term survival after resection of pancreatic adenocarcinoma.

PURPOSE: To assess clinicopathologic features and postresection survival of diabetes mellitus (DM)-associated pancreatic ductal adenocarcinoma (PDAC). METHODS: Records of resected PDAC patients from 2000 to 2007 were reviewed. DM was classified as new-onset (<24 months before PDAC) or longstanding (> or =24 months). Clinicopathologic features were compared by univariate and multivariate analyses. Survival was assessed by Kaplan-Meier method and Cox regression. RESULTS: Of 209 patients, 93 (45%) met criteria for DM (35 longstanding DM, 55 new-onset DM, 3 duration unknown). DM patients were older (DM 66 +/- 9 years, non-DM 63 +/- 12 years, P = 0.06); a majority had additional preoperative comorbidities (DM 64.5%, non-DM 25.9%, P < 0.001). Tumor size was larger in patients with DM (DM 3.8 +/- 1.7 cm, non-DM 3.2 +/- 1.5 cm, P = 0.003). Groups were similar in terms of tumor location, perineural/lymphovascular invasion, and node and margin status. On logistic regression, tumor size >/=3.0 cm was independently associated with both overall DM (odds ratio [OR] 3.60; 95% confidence interval [1.79-7.26]) and new-onset DM (OR 3.69, [1.65-8.24]). Median survival was reduced in patients with DM compared with non-DM (15 versus 17 months, P = 0.015). Multivariate analysis controlling for prognostic variables including age, comorbidities, and tumor size demonstrated that DM was independently associated with reduced survival (hazard ratio [HR] 1.55, [1.02-2.35]). This association was more pronounced for patients with new-onset DM (HR 1.75 [1.10-2.78]) than those with longstanding DM (HR 1.30 [0.75-2.25]). CONCLUSIONS: Preexisting DM is associated with reduced survival in patients undergoing resection for PDAC. PDAC with new-onset DM may exhibit increased tumor size and decreased postresection survival. Additional investigation is needed to clarify etiology and impact of PDAC-associated DM.

Laparoscopic left pancreatectomy: complication risk score correlates with morbidity and risk for pancreatic fistula.

BACKGROUND: Surgeons are performing laparoscopic left pancreatectomy (LLP) with increasing frequency; however, determinants of perioperative outcome after LLP are not well defined. We evaluated factors contributing to morbidity after LLP. METHODS: Records from patients undergoing LLP from 2000 to 2008 from nine academic medical centers were evaluated to assess risk factors for perioperative complications. Extent of pancreatic resection was determined by the length of the gross pancreatic specimen. Complications and pancreatic fistula rates were assessed, and a model was developed to identify those at risk of postoperative adverse events. RESULTS: Among the 219 LLP cases, indications were cystic neoplasms in 122 (56%), solid neoplasms in 83 (38%), and chronic pancreatitis in 14 (6%). Thirty-day morbidity and mortality were 39% and 0, respectively. Major complications occurred in 11%. Pancreatic fistulae were detected in 23%, with clinically important fistulae (International Study Group on Pancreatic Fistula Definition grade B/C) seen in 10%. On multivariate analysis, only greater estimated blood loss (EBL), higher body mass index (BMI), and longer length of resected pancreas were associated with major complications. A complication risk score consisting of 1 point each for BMI >27, pancreatic specimen length >8 cm, or EBL > or =150 mL predicted an increased risk of complications and pancreatic fistulae. CONCLUSIONS: The risk of major complications after LLP is 11%, with clinically important pancreatic fistulae occurring in 10%. A complication risk score incorporating BMI, extent of pancreatic resection, and EBL correlates with all end points evaluated. The complication risk score should be used when quality outcome measures are evaluated.

Impact of diabetes mellitus on perioperative outcomes after resection for pancreatic adenocarcinoma.

BACKGROUND: Associations between diabetes mellitus (DM) and pancreatic ductal adenocarcinoma (PDAC) are well established; however, the impact of DM on perioperative morbidity and mortality after PDAC resection is unclear. STUDY DESIGN: A prospectively maintained database review identified all patients undergoing PDAC resection between January 1, 2000, and December 31, 2008. Diagnosis of DM was established by history and biochemical profile. Records were reviewed for comorbidities, operative variables, and histologic parameters. Postoperative morbidity and mortality were assessed for diabetic and nondiabetic patients using standardized definitions. RESULTS: Of 251 PDAC cases, 116 (46%) patients had preoperative DM. Pancreaticoduodenectomy was performed in 220 (87.6%), left pancreatectomy in 29 (11.6%), and total pancreatectomy in 2 (0.8%). The major complication rate was 25.5%, with 60-day mortality of 3.6%. Delayed gastric emptying (DGE) occurred in 40.1% of patients. Pancreatic fistulas developed in 17 (6.8%) patients; 11 of them were clinically significant (grades B/C). DM patients had a higher likelihood of developing fistulas (DM 10.3%, non-DM 3.7%, p = 0.04). When controlled for age, comorbidities, body mass index, preoperative albumin level, operation type, operative time, and pancreatic quality, DM maintained an independent association with fistula formation (odds ratio 4.3, 95% CI 1.18 to 15.8, p = 0.027). Acute kidney injury was more frequent in the DM group (DM 23.3%, non-DM 12.6%, p = 0.03). DM and non-DM patients had similar frequency of DGE, wound infections, intra-abdominal abscesses, and cardiovascular and pulmonary complications, as well as length of stay and mortality. CONCLUSIONS: Comorbid DM does not influence perioperative outcomes dramatically after pancreatectomy for ductal adenocarcinoma. The role of PDAC-associated DM as a risk factor for postresection pancreatic fistula should be further explored. Evaluation of glycemic control and outcomes after PDAC resection may be useful.