Pancreatoduodenectomy: results in a large volume center
Departamento de Cirugía General-Clínica de Páncreas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirdn, México, D.F. Revista de gastroenterologia de Mexico
Analyze the experience with pancreaticoduodenectomy (PD) at the INCMNSZ.
PD has become a popular procedure in hospitals throughout the USA and Europe in the last 25 years, where mortality is < 5% y morbidity remains around 40%. Nonetheless there are very few reports on PD in Latin America.
The data of all PD's performed at the INCMNSZ between 1999 and 2005 was gathered prospectively and analyzed retrospectively.
133 PDs where performed; 47.5% where men and 52.5% where women. Median of age was 57.7 years. 81.5% underwent classical resection and 18.5% a pylorus preserving procedure. Intraoperative variables include: blood loss: 940 mL. (1,000). transfusion requirements: 1.9 U, median operative time: 5:49 (+/- 1:02) and median hospital stay: 14 days. Most frequent diagnosis include ampulary adenocarcinoma and pancreatic cancer Mortality in the entire series was 9.2%, decreased to 2.7% in the 2002-2005 period and from April 2003 has remained in 0. A total of 14 portal-superior mesenteric vein resections where performed.
To our knowledge this is the largest series of PD in Latin America. Popularity and indications for PD are expanding. Mortality is acceptable and morbidity remains high despite much effort. This procedure is performed with a satisfactory outcome in high volume centers. Involvement of the portal-superior mesenteric vein is not a contraindication of PD.
Available from: Alethia Rubio
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ABSTRACT: To analyze data in a single institution series of pancreaticoduodenectomies (PD) performed in a 7-year period after the transition to a high-volume center for pancreatic surgery.
PD has developed dramatically in the last century. Mortality is minimal yet complications are still frequent (around 40%). There are very few reports of PD in Latin America.
Data on all PDs performed by a single surgeon from March 2000 to July 2006 in our institution were collected prospectively.
During the study's time frame 122 PDs were performed; 84% were classical resections. Mean age was 57.9 years. Of the patients, 51% were female. Intraoperative mean values included blood loss 881 ml, operative time 5 h and 35 min, and vein resection in 14 cases. Both ampullary and pancreatic cancer accounted for 34% of cases (42 patients each), 5.7% were distal bile duct and 4% duodenal carcinomas. Benign pathology included chronic pancreatitis, neuroendocrine tumors, cystic lesions, and other miscellaneous tumors. Overall operative mortality was 6.5% in the 7-year period, 2.2% in the later 5 years. There was a total of 75 consecutive PDs without mortality. Of the patients, 41.8% had one or more complications. Mean survival for pancreatic cancer was 22.6 months and ampullary adenocarcinoma was 31.4 months.
To our knowledge, this is the largest single surgeon series of PD performed in Latin America. It emphasizes the importance of experience and expertise at high-volume centers in developing countries.
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ABSTRACT: Allogeneic blood transfusion (ABT) containing packed red blood cells (RBCs) has a known immunosuppressive effect that may affect cancer metastases and recurrence. This study examined whether intraoperative allogeneic RBC transfusion is an independent risk factor of adverse outcome in patients with ampullary carcinoma after curative pancreatoduodenectomy.
The clinical data of 67 patients with carcinoma of the ampulla of Vatar underwent pancreatoduodenectomy between 1999 and 2004 were analyzed, and long-term follow-up visits were made for all patients. Kaplan-Meier statistics and Cox proportional hazard methodology were used to perform univariate and multivariate analysis to identify independent risk factors for survival. For the meta-analysis, all English-language studies regarding blood transfusion from carcinoma of the ampulla of Vatar or ampullary carcinoma and prognostic factors or factors for survival from 1995 to 2007 were reviewed, and contingency tables were constructed from which a summary relative risk was calculated.
There were 43 patients (64.2%) who received an intraoperative ABT. The amount of intraoperative ABT ranged from 2 to 13 (mean, 4.25) units; there were 18 patients transfused at 2 units, and 25 patients transfused > or =3 units. The follow-up ranged from 2 to 90 (mean, 49) months. Forty-five patients (67.2%) died as a result of tumor progression. For patients transfused > or =3 units, median and cumulative 3-year and 5-year survivals were poorer significantly than that of patients transfused with 2 units and/or nontransfused patients (P < 0.05). After multivariate analysis, except for presence of lymph node metastasis (P = 0.023) and pancreatic invasion (P = 0.024), the intraoperative ABT > or =3 units was found to be an independent poor prognostic factor for those with ampullary cancer after curative pancreatoduodenectomy either (relative risk, 2.082; 95% confidence interval (CI), 1.048-4.135; P = 0.036). Meta-analysis of 346 patients showed the summary relative risk of an adverse outcome after intraoperative ABT in these studies was 2.55 (95% CI, 1.59-4.1).
The amount of intraoperative ABT is one of the important factors that adversely influenced survival in patients with ampullary cancer after curative pancreatoduodenectomy. Healing anemia preoperatively and careful dissection to minimize intraoperative bleeding as much as possible are mandatory for reducing risk of the intraoperative ABT.
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ABSTRACT: Introduction: Pancreatic adenocarcinoma (PA) is not only one of the most common gastrointestinal tumors, but also the most lethal. Objective: Give a comprehensive and up-to-date panorama on pancreatic cancer with a surgical focus. Methods: A critical search was performed in Medline focusing on recent relevant publications, renowned authors, high impact publications and a preference for surgical literature in English. Results: In this article we review PA epidemiology, some aspects of molecular biology, clinical presentation, work-up, staging and current treatment options. Conclusions: Patients affected must be studied appropriately and referred to specialized centers for surgical treatment, when indicated, in order to offer them the best chance for cure. Breakthroughs in management will probably include prevention, early diagnosis and molecular therapy.
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