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Cancer 04/2013; · 4.77 Impact Factor
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ABSTRACT: Routine use of operative (primary) drains after pancreaticoduodenctomy (PD) remains controversial. We reviewed our experience with PD for postoperative (secondary) drainage and postoperative pancreatic fistula (POPF) rates based on use of primary drains.
We identified consecutive patients who underwent PD between 2005 and 2012 from our pancreatectomy database. Primary closed suction drains were placed at the surgeon's discretion. Patient and operative factors were assessed, along with POPF, complications, and secondary drain placement rates.
There were 709 PDs performed, and 251 (35%) patients had primary drains placed. Age, sex, body mass index, and comorbidities were similar among groups; however, drained patients had slightly larger pancreatic ducts (mean diameter 3.8 mm vs 2.2 mm; p < 0.01). The overall secondary drainage rate was 7.1%. Primary drain placement did not affect the need for secondary drainage (with primary drain, 8.4% vs without primary drain 6.3%, p = 0.36), reoperation (5.6% vs 5.7%, p = 1.00), readmission (17.5% vs 16.8%, p = 0.89), or 30-day mortality (2.0% vs 2.5%, p = 0.80). When compared with the no drain group, patients with primary drains experienced higher rates of overall morbidity (68.1% vs 54.1%, p < 0.01) and significant POPF (16.3% vs 7.6%; p < 0.01), as well as longer hospital stays (13.8 days vs 11.3 days; p < 0.01). On multivariate analysis, primary drain placement remained an independent risk factor for pancreatic fistula formation (hazard ratio 3.3, p < 0.01), but did not have an impact on secondary drainage rates (p = 0.85).
Placement of closed suction drains during pancreaticoduodenectomy does not appear to decrease the rate of secondary drainage procedures or reoperation, and may be associated with increased pancreatic fistula formation and overall morbidity. These data support foregoing routine primary operative drainage at time of pancreaticoduodenectomy.
Journal of the American College of Surgeons 04/2013; 216(4):635-42. · 4.55 Impact Factor
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Journal of the American College of Surgeons 12/2012; 215(6):900-2. · 4.55 Impact Factor
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ABSTRACT: Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival. J. Surg. Oncol © 2012 Wiley Periodicals, Inc.
Journal of Surgical Oncology 09/2012; · 2.10 Impact Factor
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Sarah B Fisher,
Sameer H Patel,
David A Kooby,
Sharon Weber,
Mark Bloomston,
Clifford Cho,
Ioannis Hatzaras,
Carl Schmidt,
Emily Winslow,
Charles A Staley,
Shishir K Maithel
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ABSTRACT: Criteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.
A total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).
Median OS was 23.0 months. Median tumour size was 6.5 cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6 months vs. 32.7 months (P= 0.020) and 10.7 months vs. 32.7 months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7 months vs. 30.0 months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1 months vs. 10.7 months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio 4.07, 95% confidence interval 1.60-10.40; P= 0.003).
Lymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy.
HPB 08/2012; 14(8):514-22. · 1.60 Impact Factor
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ABSTRACT: BACKGROUND: Tumor expression of excision cross-complementing gene-1 (ERCC1), human equilibrative nucleoside transporter 1 (hENT1), ribonucleotide reductase subunit M1 (RRM1), and ribonucleotide reductase subunit M2 (RRM2), is associated with the efficacy of platinum and gemcitabine chemotherapy. The authors of this report recently demonstrated that high ERCC1 and RRM2 expression levels are independent negative prognostic markers for survival in early stage pancreas cancer. The differential expression and prognostic value of these biomarkers in biliary tract malignancy (BTM) is unknown. METHODS: In total, 63 patients who had tissue available for analysis were selected from a prospective database of all patients (n = 104) who underwent resection of BTM (intrahepatic, hilar, or distal cholangiocarcinoma; gallbladder carcinoma) between January 2000 and December 2008. Immunohistochemistry for ERCC1, hENT1, RRM1, and RRM2 expression was performed. Staining was scored by a single pathologist who was blinded to patient outcomes. RESULTS: The median patient age was 67 years. The median overall survival (OS) was 16.2 months, and the median follow-up was 32.7 months. Only 3 BTMs (4.8%) had high ERCC1 expression, and 92.1% and 81% of BTMs exhibited high hENT1 and RRM1 expression, respectively. RRM2 expression varied, and 32% of tumors demonstrated high RRM2 expression. ERCC1 and RRM1 were not associated with OS. High RRM2 expression was associated with a trend toward improved OS (30.8 months vs 16.2 months; P = .06), and high hENT1 expression was associated with improved OS (17.7 months vs 9.5 months; P = .04). CONCLUSIONS: Most BTMs exhibited low ERCC1 expression and high hENT1 and RRM1 expression, whereas RRM2 expression levels varied. High expression of hENT1 was associated with improved OS. These findings may have implications for the selection of chemotherapy agents (gemcitabine vs platinum) and the stratification of patients in chemotherapy trials that assess outcome. Cancer 2012. © 2012 American Cancer Society.
Cancer 07/2012; · 4.77 Impact Factor
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ABSTRACT: As compared with open distal pancreatectomy, laparoscopic distal pancreatectomy (LDP) is associated with lower morbidity and shorter hospital stays. Existing reports do not elucidate trends in patient selection, technique, and outcomes over time. We aimed to determine outcomes after LDP at a specialized center, analyze trends of patient selection and operative technique, and validate a complication risk score (CRS).
Patients undergoing LDP between January 2000 and January 2011 were identified and divided into 2 equal groups to represent our early and recent experiences. Demographics, tumor characteristics, operative technique, and perioperative outcomes were examined and compared between groups. A CRS was calculated for the entire cohort and examined against observed outcomes.
A total of 132 LDPs were attempted, of which 8 (6.1%) were converted to open procedures. Thirty-day overall and major complication rates were 43.2% and 12.9%, respectively, with mortality < 1%. Pancreatic fistulas occurred in 28 (21%) patients, of which 14 (11%) were clinically significant. Recent LDPs (n = 66) included patients with increasingly severe comorbidities (Charlson scores > 2, 40.9% vs 16.7%, p = 0.003), more proximal tumors (74.2% vs 26.2%, p < 0.001), more extended resections (10.6 vs 8.3 cm, p < 0.001), shorter operative times (141 vs 172 minutes, p = 0.007), and less frequent use of a hand port (25.8% vs 66.6%, p < 0.001). No significant differences were found in perioperative outcomes between the groups. As compared with the hand access technique, the total laparoscopic approach was associated with shorter hospital stays (5.3 vs 6.8 days, p = 0.032). Increasing CRS was associated with longer operative time, significant fistulas, wound infections, blood transfusions, major complications, ICU readmissions, and rehospitalizations.
This large, single-institution series demonstrates that despite a shift in patient selection to sicker patients with more proximal tumors, similar perioperative outcomes can be achieved with laparoscopic distal pancreatectomy. The CRS appears to be a reliable preoperative assessment tool for assessing other adverse perioperative outcomes in addition to predicting overall complications and fistulas as originally published.
Journal of the American College of Surgeons 05/2012; 215(2):167-76. · 4.55 Impact Factor
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ABSTRACT: BACKGROUND: Tumor overexpression of excision repair cross-complementing gene-1 (ERCC1) may be associated with decreased survival in patients with pancreas adenocarcinoma (PAC). Human equilibrative nucleoside transporter-1 (hENT1) and ribonucleoside reductase subunits M1 and M2 (RRM1 and RRM2) are integral to cellular transport and DNA synthesis and are implicated as poor prognostic factors in other malignancies. To the authors's knowledge, their role in PAC is not defined. METHODS: A prospective database was used to randomly select 95 patients who underwent pancreaticoduodenectomy for PAC between January 2000 and October 2008. Immunohistochemical analysis was performed on tumor samples for hENT1, RRM1 and RRM2, and ERCC1. Main outcomes were recurrence-free survival (RFS) and overall survival (OS). RESULTS: The median follow-up, RFS, and OS were 49 months, 10.6 months, and 15.5 months, respectively. The median tumor size was 3 cm. Approximately 26% of patients had positive microscopic margins, 61% had lymph node involvement, and 88% and 45% had perineural and lymphovascular invasion, respectively. High tumor expression of hENT1, RRM1, RRM2, and ERCC1 was present in 85%, 40%, 17%, and 16%, respectively, of patients. High hENT1 expression was associated with reduced RFS (9.5 months vs 44.5 months; P = .029), but not with OS. RRM1 expression was not associated with survival. High RRM2 expression was associated with reduced RFS (6.9 months vs 16.0 months; P < .0001) and decreased OS (9.1 months vs 18.4 months; P < .0001). High ERCC1 expression was associated with reduced RFS (6.1 months vs 15 months; P = .04) and decreased OS (8.9 months vs 18.1 months; P = .03). After accounting for known adverse tumor factors, high expression of RRM2 and ERCC1 persisted as negative prognostic factors for RFS and OS. A subset analysis of patients who received adjuvant therapy (n = 74) revealed the same negative effect of high RRM2 and ERCC1 expression on RFS and OS. CONCLUSIONS: High tumor expression of RRM2 and ERCC1 are associated with reduced RFS and OS after resection of pancreas cancer. These biomarkers may help to personalize adjuvant therapy. Cancer 2012. © 2012 American Cancer Society.
Cancer 05/2012; · 4.77 Impact Factor
