Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy.

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer.

BACKGROUND: Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer. METHODS: A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included. RESULTS: After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months. CONCLUSION: Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.

Health-related Quality of Life and Functional Outcomes in 5-year Survivors After Pancreaticoduodenectomy.

OBJECTIVE: Our aim was to assess quality of life (QOL) and functionality in a large cohort of patients ≥5-years after pancreaticoduodenectomy (PD). BACKGROUND: Long-term QOL outcomes after PD for benign or malignant disease are largely undocumented. METHODS: We administered the EORTC QLQ-C30 questionnaire to patients who underwent PD for neoplasms from 1998 to 2011 and compared their scores with an age- and sex-matched normal population. Clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (>20) based on validated interpretation of clinically important differences. RESULTS: Of 305 PD survivors, 245 (80.3%) responded, of whom 157 (64.1%) underwent PD for nonmalignant lesions. Median follow-up was 9.1 years (range 5.1 -21.2 yrs). New-onset diabetes developed in 10.6%; 50.4% reported taking pancreatic enzymes; 54.6% reported needing antacids. Compared with the age- and sex-adjusted controls, PD survivors demonstrated higher global QOL (78.7 vs 69.7, CR small, P < 0.001), physical (86.7 vs 77.9, CR small, P < 0.001) and role-functioning scores (86.3 vs 74.1, CR medium, P < 0.001). Using linear regression and adjusting for socioeconomic variables, there were no differences in QOL or functional scores in the benign versus malignant subgroups. Older age at operation was associated with worse physical-functioning (-0.4/yr, P = 0.008). Taking pancrelipase (-6.8, P = 0.035) or antacids (-6.3, P = 0.044) were both associated with lower social-functioning scores. CONCLUSIONS: Patients who had a PD demonstrated better global QOL, physical- and role-functioning scores at 5-years when compared with age- and sex-matched controls. Approximately half of the patients required pancreatic enzyme replacement, while only 11% developed new-onset diabetes.

Quality of life in patients with pancreatic ductal adenocarcinoma undergoing pancreaticoduodenectomy.

INTRODUCTION: Survival for pancreatic ductal adenocarcinoma (PDAC) is relatively short even after complete resection. Pancreaticoduodenectomy (PD) carries a high risk for postoperative morbidity, and the effect on quality of life (QoL) is unclear. We aimed to study QoL in PDAC patients undergoing PD. PATIENTS AND METHODS: Sixty patients with suspected PDAC and planned PD were asked to complete EORTC QoL questionnaires QLQ-C30 and QLQ-PAN26 preoperatively and at 3-6-12-18-24 months postoperatively. RESULTS: 47 PDAC patients who underwent PD (66 (21-84) years, 53% men) were included. Follow-up was completed by 81% (6 months) and 45% (24 months) post-PD. Compared to preoperative level, QoL tended to improve or remained the same in 63% during the follow-up. At three months after PD patients had less hepatic symptoms (decreased by 100%; p < 0.001), pancreatic pain and sexuality symptoms tended to decrease by 33% and global and functional QoL tended to slightly improve. These parameters remained at the achieved level during the longer follow-up. A temporary rising tendency was seen in digestive symptoms at three months but this later reverted to the preoperative level. More altered bowel movements and sexuality symptoms tended to arise during the longer follow-up. A negative correlation was found between reported financial difficulties and length of survival. CONCLUSIONS: PD does not worsen the QoL in most of the patients with PDAC. The potentially beneficial effect on QoL is apparent already at three months after surgery. This information may be helpful for the clinician and patient, when deciding on the treatment for PDAC.

Quality of life after pancreatic surgery.

BACKGROUND: Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas. Increasing attention has been paid to changes in quality of life (QOL) after pancreatic surgery. AIM: To summarize and analyze current research results on QOL after pancreatic surgery. METHODS: A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were identified by screening the references of retrieved articles. Studies on patients' QOL after pancreatic surgery published after January 1, 2012, were included. These included prospective and retrospective studies on patients' QOL after several types of pancreatic surgeries. The results of these primary studies were summarized inductively. RESULTS: A total of 45 articles were included in the study, of which 13 were related to pancreaticoduodenectomy (PD), seven to duodenum-preserving pancreatic head resection (DPPHR), nine to distal pancreatectomy (DP), two to central pancreatectomy (CP), and 14 to total pancreatectomy (TP). Some studies showed that 3-6 months were needed for QOL recovery after PD, whereas others showed that 6-12 months was more accurate. Although TP and PD had similar influences on QOL, patients needed longer to recover to preoperative or baseline levels after TP. The QOL was better after DPPHR than PD. However, the superiority of the QOL between patients who underwent CP and PD remains controversial. The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL. Minimally invasive surgery could improve patients' QOL in the early stages after PD and DP; however, the long-term effect remains unclear. CONCLUSION: The procedure among PD, DP, CP, and TP with a superior postoperative QOL is controversial. The long-term benefits of minimally invasive versus open surgeries remain unclear. Further prospective trials are warranted.

'It's always in the back of my mind': understanding the psychological impact of recovery following pancreaticoduodenectomy for cancer: a qualitative study.

OBJECTIVES: Ten per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs impact negatively on quality of life. This paper reports the psychological impact of a pancreatic cancer diagnosis and subsequent pancreaticoduodenectomy, exploring how patients' lives alter following surgery and how they seek support. DESIGN: Inductive qualitative study involving in-depth semistructured interviews with 20 participants who had undergone pancreaticoduodenectomy for pancreatic or distal biliary duct cancer. Interviews were audiorecorded, transcribed and anonymised, and thematic analysis used principles of constant comparison. SETTING: Single National Health Service Trust in Northwest England. PARTICIPANTS: Patients were eligible for inclusion if they had had pancreaticoduodenectomy for head of pancreas cancer, periampullary cancer or distal cholangiocarcinoma between 6 months and 6 years previously, and had completed adjuvant chemotherapy. RESULTS: Analysis identified the following main themes: diagnosis and decision making around surgery; recovery from surgery and chemotherapy; burden of monitoring and ongoing symptoms; adjusting to 'a new normal'; understanding around prognosis; support-seeking. Participants seized the chance to have surgery, often without seeming to absorb the risks or their prognosis. They perceived that they were unable to control their life trajectory and, although they valued close monitoring, experienced anxiety around their appointments. Participants expressed uncertainty about whether they would be able to return to their former activities. There were tensions in their comments about support-seeking, but most felt that emotional support should be offered proactively. CONCLUSIONS: Patients should be made aware of potential psychological sequelae, and that treatment completion may trigger the need for more support. Clinical nurse specialists (CNSs) were identified as key members of the team in proactively offering support; further training for CNSs should be encouraged. Understanding patients' experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.

Operative results and patient satisfaction after robotic pancreaticoduodenectomy.

BACKGROUND/OBJECTIVE: There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD. METHODS: Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD. RESULTS: The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications ≥ Clavien-Dindo III occurred in 7.6% of the total 105 RPD patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all of the patients responded to this RPD-related survey with "fair" to "excellent" grades for all items, except 1 (<1%) poor grade for operation service and 2 (1.9%) "not good" grades for diet tolerance. CONCLUSIONS: RPD is a feasible procedure with acceptable surgical outcomes. This patient survey with high patient satisfaction rates indicates that RPD provides acceptable satisfaction results, and the robotic approach for a major operation such as RPD has probably a higher priority than cost concerns. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction.

Symptoms and self-care following pancreaticoduodenectomy: Perspectives from patients and healthcare professionals - Foundation for an interactive ICT application.

PURPOSE: Poor prognosis and a problematic recovery period after pancreaticoduodenectomy means that patients may benefit from early detection of symptoms and support for self-management. Interactive Information and Communication Technology tools can be used for this purpose, but the content needs to be relevant to patients as well as healthcare professionals. To facilitate development of the content of an application for this purpose, the aim of this study was to explore common symptoms and self-care in the first six months after pancreaticoduodenectomy, as identified by patients and healthcare professionals. METHOD: Data were collected through individual interviews with patients (n = 14), along with two focus group interviews and one individual interview with healthcare professionals (n = 10). Data were analysed using qualitative content analysis. RESULTS: Common symptoms after surgery were those related to eating, bowel function and emotional wellbeing, along with fatigue and pain. Some self-care activities and advice were mentioned in the interviews. The patients often experienced a lack of advice on self-care at discharge. CONCLUSIONS: The results render knowledge of the symptoms it is important to be aware of and to assess regularly after pancreaticoduodenectomy. The results also contribute to knowledge about specific self-care related to these symptoms, even though it was not extensively described, and further research is needed to define evidence-based self-care advice.

Long-term quality of life following pancreaticoduodenectomy.

BACKGROUND/AIMS: This study examined long-term quality of life in an unselected consecutive cohort of patients undergoing pancreaticoduodenectomy, both Whipple and total, for benign and malignant disease. METHODOLOGY: Forty consecutive patients who underwent pancreaticoduodenectomy over a nine-year period formed the study group. The control group consisted of 58 age- and sex-matched patients undergoing open cholecystectomy during the same period. Quality of Life was assessed using the European Organisation for Research and Treatment of Cancer QLQ-C30 (core cancer module) and QLQ-PAN26 (pancreatic cancer module) questionnaires at a median of 42 months postoperatively. RESULTS: The Global Health Status of the study and control groups was similar, but significant differences were noted in certain individual scales. The benign group reported greater social and financial difficulties, and symptoms consistent with impaired exocrine function. The malignant group reported difficulties with daily physical and role functioning, concern for future health and individual symptoms such as fatigue, muscle weakness, and inability to gain weight. CONCLUSIONS: This study demonstrates that the overall quality of life of patients who underwent pancreaticoduodenectomy compared favorably with that of a control group. Significant differences did exist in some individual scales, in both the benign and malignant sub-groups, suggestive of exocrine insufficiency.

Outcome analysis of long-term survivors following pancreaticoduodenectomy.

The long-term sequelae of pancreaticoduodenectomy are not completely understood. In the present study nutritional status, pancreatic function, and subjective quality-of-life parameters were evaluated in 45 patients who had previously undergone either pylorus-preserving pancreaticoduodenectomy (PPPD) or standard pancreaticoduodenectomy (SPD). Quality-of-life parameters, as measured by the Short Form-36 health survey, demonstrated no significant differences between the subgroups and normal control subjects in six of the eight domains for physical and mental health. Patients who had undergone SPD were noted to have significantly lower scores for general health and vitality than either age-matched control subjects or those who had undergone PPPD. No differences in nutritional parameters or indicators of pancreatic exocrine function between the two groups were identified. An elevated hemoglobin A1c value was seen in only one patient who was not diabetic preoperatively. Our data indicate that long-term survivors of pancreaticoduodenectomy generally feel as good as their normal counterparts, although SPD may result in some health satisfaction deficits. Nutritional status and pancreatic exocrine function are not improved in patients undergoing a pylorus-preserving procedure, and postoperative pancreatic endocrine dysfunction is unusual in both groups.

Assessment of the learning curve for pancreaticoduodenectomy.

BACKGROUND: Experience with the Whipple procedure has been associated with improved outcomes, but the learning curve for this complex procedure is not well defined. METHODS: Outcomes with 162 consecutive Whipple procedures during the 1st 11.5 years of practice was documented in a prospective database. A period of low (≤11/y) and high (≥23/y) case volume was compared using the Wilcoxon rank-sum test and Fisher exact test. RESULTS: With low case volume, blood loss was higher (800 vs 400 mL, P = .001), more patients were transfused (44% vs 18%, P = .027), there were more complications (58% vs 46%, P = .0337), and a longer length of stay (10 vs 7 days, P = .006). There was only 1 mortality (.7%). CONCLUSIONS: Frequent repetition of the Whipple procedure is associated with an improvement in quantifiable quality benchmarks, and improvement continues with extensive experience. However, with proper training and the right environment, this procedure can be performed during the learning curve with acceptable outcomes.

Impact on quality of life after pancreatoduodenectomy: a prospective study comparing preoperative and postoperative scores.

INTRODUCTION: Few studies compare the direct impact of pancreatoduodenectomy (PD) on the patient's quality of life (QOL). The effect of PD in QOL, comparing the preoperative vs. postoperative status, was analyzed. METHOD: A prospective single-center study was performed. PD patients in a 2-year period were included. A general QOL instrument was applied preoperative, 1, 3, 6, and 12 months after surgery and compared with national norms. RESULTS: Thirty-seven patients were recruited. Twenty of 37 were female. Ampullary carcinoma 14/37, ductal adenocarcinoma in 9/37, and other malignant neoplasms 14/37 were diagnosed. Mortality was absent; 48.6% had complications, 13.5 % required reoperation. Three (median) and 4 (mode) questionnaires were answered per individual. 85 % answered the last questionnaire. 4/37 had cancer related death before a year. Median follow-up was 29 (3-72) months. QOL diminished a month after surgery, physical function (67 vs 40, p<0.0001) and emotional role (37 vs 17, p<0.032) did so significantly. Three months after surgery QOL improved yet not significantly. Six and 12 months postoperatively, physical role (9 vs 49, p=0.001), physical pain (51 vs 71, p=0.01), social function (52 vs 63, p=0.014), vitality (54 vs 64, p=0.018), and emotional role (41 vs 69, p=0.006) improved significantly. DISCUSSION: PD has a favorable impact in quality of life as demonstrated by the improvement of most parameters assessed in the postoperative period.

Quality of life in patients after pancreaticoduodenectomy for chronic pancreatitis.

PURPOSE: Pancreaticoduodenectomy (PD) is the most frequently performed resectional procedure in chronic pancreatitis. Only a few studies have evaluated quality of life (QOL) after PD for chronic pancreatitis. This retrospective study examined long-term quality of life and relief of symptoms in a homogenous consecutive cohort of 67 patients undergoing PD for chronic pancreatitis. METHODS: A standard QOL questionnaire was sent to 168 patients after PD who had undergone PD for chronic pancreatitis at the University Hospital Dresden between 1994 and 2008. QOL and long-term sequelae were evaluated by the EORTC quality of life questionnaire supplemented with complementary questions. Results were compared to general population data based on large random samples. RESULTS: Median follow-up was 69.1 months. Complete response was obtained from 67 (48.5%) patients. Long-term survival of our patients was lower than expected rates based on the Federal Republic of Germany life table analysis (p < 0.001). There was an improved pain control and an increase in weight gain. Overall, QOL scores were slightly inferior to those of the control group. A common problem after PD was onset of diabetes mellitus; however, exocrine function of the pancreas was stable. CONCLUSIONS: This is the largest single-institution experience assessing QOL after PD for chronic pancreatitis. Most patients have QOL scores comparable to those of the control patients and can function independently in daily activities.

Clinical and patient-reported outcomes after pancreatoduodenectomy for different diseases: a follow-up study.

OBJECTIVE: The objective of the study was to evaluate clinical features and quality of life (QoL) in a 2-year follow-up study in subjects who underwent pancreatic head resection (PHR). METHODS: One hundred ninety-seven patients with benign and malignant diseases who underwent PHR were studied. A dedicated clinical form and the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire C-30 were administered at evaluation times (immediately before surgery and 6, 12, 18, and 24 months after discharge). A sample of 197 sex- and age-matched norms was also included into the study as reference group. RESULTS: Of the 197 patients studied, 164 (83.2%) had malignant disease, and 33 had benign disease (16.8%). At initial evaluation, global health was significantly lower (P = 0.001) in the study population as compared with the norms. At the end of the study, the QoL was not significantly different from the norms, although the QoL of the 30 patients with benign disease was significantly better than that of the 72 patients with malignant disease. CONCLUSIONS: The QoL before PHR was impaired in study patients before resection as compared with the normative population, whereas in patients who survived resection, it significantly improved in the 24 months after surgery.

[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]. / Uberleben, Mortalität und Lebensqualität nach pyloruserhaltender oder klassischer Whipple-Operation. Systematische Ubersichtsarbeit mit Metaanalyse.

BACKGROUND: Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation. METHODS: This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma). RESULTS: The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation. CONCLUSIONS: Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.

Pancreaticoduodenectomy with pancreaticogastrostomy: assessment of patients' nutritional status, quality of life and pancreatic exocrine function.

BACKGROUND: The changes in digestive function of patients with pancreaticoduodenectomy (PD) and pancreaticogastrostomy reconstruction have not been well-documented. The present study sought to assess the nutritional status, quality of life and pancreatic exocrine function in this group of patients. METHODS: The study group consisted of 11 PD with pancreaticogastrostomy patients. The control group consisted of 11 consecutive patients who had subtotal gastrectomy (SG) for distal stomach tumours. RESULTS: The median ages for the PD and SG groups were 57 and 59 years, respectively. The median intervals between surgery to assessment were 68 and 60 weeks, respectively. The PD group attained a mean of 92.7% of their pre-surgery weight compared to 91.3% in the SG group. Both groups had a comparable gastrointestinal quality of life index and Visick scale scores. Exocrine insufficiency using the faecal chymotrypsin test was present in 36% of patients with PD. None of the patients in the SG group had exocrine insufficiency. CONCLUSION: Pancreaticoduodenectomy patients had a significant occurrence of pancreatic exocrine insufficiency compared to the SG group. But patients with PD and pancreaticogastrostomy reconstruction maintained a nutritional status and quality of life similar to those with curative SG for stomach malignancy. Apart from exocrine insufficiency, the concomitant gastrectomy in the PD group is an important factor responsible for their inability to gain weight.