Background The prognosis of patients with liver metastasis is generally considered dismal, and combined resections of the primary tumor and metastasectomies are not recommended. In highly selected ...patients, however, resections are performed. The evidence for this indication is limited. The aim of the current study was to assess the operative and oncologic outcomes of patients with combined pancreatic and liver resections of synchronous liver metastases. Methods In a retrospective analysis of 6 European pancreas centers, we identified 69 patients with pancreatic ductal adenocarcinoma and synchronous liver metastasis who underwent simultaneous pancreas and liver metastasis resections. Patients receiving exploration without tumor resection served as the control group. Results Overall survival (OS) appeared to be prolonged in the group of resected patients (median 14 vs 8 months, P < .001). Subgroup analysis revealed that the survival benefit of the resected patients was driven by pancreatic ductal adenocarcinomas localized in the pancreatic head (median OS 13.6 vs 7 months, P < .001). Body/tail pancreatic ductal adenocarcinomas showed no benefit of resection (median OS 14 vs 15 months, P = .312). In the multivariate analysis, tumor resection was the only independent prognosticator for OS (hazard ratio 2.044, 95% confidence interval 1.342–3.114). Conclusion The data of this retrospective and selective patient cohort suggested a clear survival benefit for patients undergoing synchronous pancreas and liver resections for pancreatic ductal adenocarcinoma, but due to the limitations of this retrospective study and very strong potential for selection bias, a strong conclusion for resection cannot be drawn. Prospective trials must validate these data and investigate the use of combined operative and systemic treatments in case of resectable metastatic pancreatic cancer. Is it time for a multicenter, prospective trial?
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Summary Although millions of cells are shed from a tumour every day, haematogenous metastasis is believed to be very inefficient. This inefficiency is widely assumed to be a result of the destruction ...of cells in the bloodstream by shear stress and the immune system and a slow rate of extravasation and proliferation in the stroma at a secondary site. Here, we propose that, whereas active intravasation of cells into the circulation is important in some tumours, others might shed cells passively into the blood or lymphatic vessels without the involvement of active cell migration. We discuss the evidence for and against this passive-shedding hypothesis and the implications for future treatments.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Chronic pancreatitis is a chronic inflammatory disorder characterized by progressive fibrosis of pancreatic tissue. The principal symptom is chronic pain resulting in reduced quality of ...life and inability to work. Short-term follow-up has shown that duodenum-preserving pancreatic head resections (DPPHRs) are superior in outcomes to pancreaticoduodenectomy. Therefore, these organ-sparing procedures have gained wide acceptance. This trial was conducted to compare patient outcomes 16 years after treatment for chronic pancreatitis by means of the Beger or the Frey procedure. Study Design Seventy-four patients suffering from chronic pancreatitis were randomly assigned to 2 treatment groups (Beger n = 38) and Frey (n = 36). The perioperative courses in the randomized controlled trial and the 8-year follow-up have been reported previously. All participating patients were contacted with a standardized, validated questionnaire to evaluate long-term survival, quality of life, pain, and exocrine and endocrine function. Results No significant differences between the 2 groups in terms of quality of life, pain control, or other somatic parameters were detected after a median of 16 years postoperatively. Mortality was comparable after Beger and Frey procedures at 39% vs 34%, respectively, with postoperative survivals of 13.0 ± 1.1 years and 13.3 ± 0.9 years, respectively (p = 0.660). No statistically significant differences were found in rates of endocrine insufficiency (Beger 87% vs Frey 86%; p = 0.953) or exocrine insufficiency (Beger 77% vs Frey 83%; p = 0.655). Conclusions Duodenum-preserving resections of the pancreatic head offered good and permanent pain relief and substantially increased quality of life in chronic pancreatitis. Overall, a 16-year long-term follow-up found comparable outcomes for the Beger and Frey procedures.
Abstract Background The activated leukocyte cell adhesion molecule (ALCAM, CD166) has been reported to be involved in tumorigenesis of colorectal cancer (CRC) and to function as a cancer stem cell ...marker. Controversial data exist regarding the prognostic power of ALCAM expression in CRC. Here, we evaluate the expression of ALCAM in a cohort of CRC patients and its usage as a prognostic marker for survival. Materials and methods Tissue specimens from 299 patients with CRC treated between 1993 and 2006 were analyzed via ALCAM immunohistochemistry (clone MOG/07) using a tissue microarray. Results were correlated with clinical, histopathological, and patient survival data (Chi-square test, Kaplan–Meier analysis, and log-rank test, respectively). Multivariate analysis also was performed (Cox regression). Results ALCAM is expressed in most primary (76%) and secondary (62%) CRC lesions ( P = 0.014). Immunohistochemistry revealed an inverse association with tumor grading ( P = 0.002) but not with any other clinical or histopathological data. Kaplan–Meier survival analysis revealed a significant overall survival benefit in the group of ALCAM-positive patients ( P = 0.019). Multivariate analysis showed that ALCAM is an independent positive prognostic marker for overall survival ( P = 0.023). Conclusions ALCAM expression is a positive prognostic marker for overall survival of CRC patients, and its detection might help to optimize the existing prognostic staging system. Elevated expression in higher differentiated tumors might indicate a potential role in the early steps of tumorigenesis, and its loss might be associated with reduced cellular adhesion, resulting in a higher metastatic potential of the tumor. Further studies must be conducted investigating these hypotheses.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Objective The aim of this study was to assess the influence of lymphatic and vascular invasion on overall survival in patients with surgically resected non–small cell lung cancer (NSCLC) without ...lymph node and distant metastases. Methods From January 1999 to December 2009, a total of 190 NSCLC patients with node-negative pT1-pT4 disease underwent radical resection with lymphadenectomy. Pathologic reports were reclassified to the TNM-7 version, and the influence of lymphatic and vascular invasion on overall survival was examined using Kaplan-Meier and adjusted Cox proportional hazards analyses. Results Lymphatic invasion was present in 34 (17.9%) and vascular invasion in 28 (14.7%) of 190 cases. Lymphatic and vascular invasions were correlated with higher Union for International Cancer Control stages ( P = .056 and P = .011, respectively) and poor differentiated tumors ( P = .051 and P = .012, respectively). There was no difference between pT1a and pT1b tumors in the presence of lymphatic ( P = .912) or vascular ( P = .134) invasion. Survival analyses revealed lymphatic ( P < .001) and vascular ( P = .008) invasion as statistically significant for the entire study population. Multivariable Cox analysis adjusted for age, Union for International Cancer Control stage, and lymphatic and vascular invasion confirmed lymphatic, but not vascular, invasion as an independent prognostic factor ( P < .001; hazard ratio, 3.002; 95% confidence interval, 1.780-5.061). Especially in early stages, lymphatic invasion was associated with poorer overall survival in pT1a ( P < .001), pT1b ( P = .019), and pT2a ( P = .028) tumors. Conclusions Lymphatic invasion represents an independent risk factor for node-negative NSCLC. Its implications on therapy decision making should be further evaluated, especially in early stages.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Whether patients with focal pancreatic lesions of benign or borderline pathology should be treated by extended central pancreatectomy rather than by extended classic resectional ...procedures, such as extended right and left resections, is controversial. Methods Between 1992 and 2007, 105 patients underwent operation for focal pancreatic lesions of borderline or benign neuroendocrine neoplasms, cystadenoma, intraductal papillary mucinous neoplasia (IPMN), and secondary metastasis. In all, 35 patients were subjected to extended central pancreatectomy, whereas the remaining 70 patients were treated by an extended classic right resection or an extended classic left resection. Groups were matched according to age, sex, and histopathology. Results No peri-operative mortality occurred after extended central pancreatectomy and extended classic left resection ( n = 35, each). Two (6%) patients died after extended classic right resection. Overall, in-hospital morbidity was 26% after extended central pancreatectomy, 43% after extended classic right resection, and 37% after extended classic left resection. After a median follow-up of 48 months, a local recurrence rate of 17% after extended central pancreatectomy was similar to the corresponding rates of 9% after extended classic left resection and 14% after extended classic right resection. Endocrine and exocrine impairment was less pronounced after extended central pancreatectomy (6% and 9%) than after extended classic left resection (34% and 29%) and extended classic right resection (28% and 24%; P < .05). Conclusion Extended central pancreatectomy for appropriate pancreatic neoplasms is associated with less peri-operative morbidity and mortality than after extended classic left and extended classic right resection. Long-term local recurrence after extended central pancreatectomy is similar to the recurrence rates after extended classic right and classic left resection. Our results suggest that appropriately selected patients will benefit from extended central pancreatectomy because of the maintenance of endocrine and exocrine function.
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BackgroundPostoperative anastomotic leakage remains a major complication of esophagectomy. The development of a reliable method of early detection of anastomotic leakage can revolutionize the ...management of esophageal carcinoma. Materials and MethodsThis is a retrospective data analysis of 147 patients who underwent Ivor-Lewis esophagectomy as a curative attempt to treat distal esophageal carcinoma in our surgery department between 2010 and 2021. C-reactive protein and white blood cell count in postoperative days 1, 3, 5, and 8 were compared in patients with and without anastomotic leakage. The diagnostic accuracy of these tests was challenged against the clinical reference standard represented by computed tomography or upper gastrointestinal endoscopy. ResultsTwenty-eight patients (19%) developed anastomotic leakage. C-reactive protein values in postoperative day 8 were the only parameter to qualify as a potential clinically helpful test with an area under the receiver operating curve of 0.85 and a P value of less than .01. We calculated the cutoff value for C-reactive protein during postoperative day 8 to be 10.85 mg/dL with specificity and sensitivity of 73.1% and 89.3%, respectively. C-reactive protein showed a positive predictive value of 43.9% and a negative predictive value of 96.7% at this cutoff value. ConclusionAn absolute diagnostic value of postoperative estimation of serum inflammatory biomarkers to detect anastomotic leakage could not be proved. Serum C-reactive protein on postoperative day 8 with a cutoff value of 10.85 mg/dL could be used to exclude anastomotic leakage after esophagectomy to serve as one of the discharge criteria of the patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background A subgroup of patients with chronic pancreatitis and severe incapacitating pain develop mesentericoportal vascular complications with extrahepatic portal hypertension (EPH) and subsequent ...cavernous transformation. The purpose of this study was to address the question of whether a noninterventional approach regarding surgery is justified. Methods A total of 702 patients with chronic pancreatitis underwent major pancreatic surgery. EPH with cavernous transformation was diagnosed in 21 (3%; group C) and EPH without cavernous transformation in 60 (9%; group B). The remaining 621 patients (88%; group A) showed no evidence for extrahepatic hypertension or cavernous transformation. Prospectively collected data were analyzed with respect to perioperative parameters, outcomes, quality of life, and our previously established pain score. Results Patients in groups C and B had longer history and greater severity of pain ( P = .0001). Group C had the longest operative times ( P > .05) and greatest requirements of intraoperatively transfused packed red blood cells ( P < .05). Morbidity was greater in group C compared with groups B and A (88% vs 55% vs 35%; P < .001). Mortality was 10% (2/21) in group C, compared with 1.3% (8/621) in group A and 0% in group B ( P = .008). Quality of life as well as pain scores significantly improved postoperatively in group C, and were comparable to those in groups A and B ( P < .001). Conclusion Concomitant cavernous transformation in patients with chronic pancreatitis increases the operative risk significantly. Alternative treatment modalities should be evaluated thoroughly in every individual patient to offer every patient the best available treatment. Nevertheless, operative intervention is often the only treatment possible and improvements in quality of life and pain alleviation justify operative interventions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background This position statement was developed to expedite a consensus on definition and treatment for borderline resectable pancreatic ductal adenocarcinoma (BRPC) that would have worldwide ...acceptability. Methods An international panel of pancreatic surgeons from well-established, high-volume centers collaborated on a literature review and development of consensus on issues related to borderline resectable pancreatic cancer. Results The International Study Group of Pancreatic Surgery (ISGPS) supports the National Comprehensive Cancer Network criteria for the definition of BRPC. Current evidence supports operative exploration and resection in the case of involvement of the mesentericoportal venous axis; in addition, a new classification of extrahepatic mesentericoportal venous resections is proposed by the ISGPS. Suspicion of arterial involvement should lead to exploration to confirm the imaging-based findings. Formal arterial resections are not recommended; however, in exceptional circumstances, individual therapeutic approaches may be evaluated under experimental protocols. The ISGPS endorses the recommendations for specimen examination and the definition of an R1 resection (tumor within 1 mm from the margin) used by the British Royal College of Pathologists. Standard preoperative diagnostics for BRPC may include: (1) serum levels of CA19-9, because CA19-9 levels predict survival in large retrospective series; and also (2) the modified Glasgow Prognostic Score and the neutrophil/lymphocyte ratio because of the prognostic relevance of the systemic inflammatory response. Various regimens of neoadjuvant therapy are recommended only in the setting of prospective trials at high-volume centers. Conclusion Current evidence justifies portomesenteric venous resection in patients with BRPC. Basic definitions were identified, that are currently lacking but that are needed to obtain further evidence and improvement for this important patient subgroup. A consensus for each topic is given.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No international ...consensus definition or grading system of chyle leak currently is available. Methods The International Study Group on Pancreatic Surgery, an international panel of pancreatic surgeons working in well-known, high-volume centers, reviewed the literature and worked together to establish a consensus on the definition and classification of chyle leak after pancreatic operation. Results Chyle leak was defined as output of milky-colored fluid from a drain, drain site, or wound on or after postoperative day 3, with a triglyceride content ≥110 mg/dL (≥1.2 mmol/L). Three different grades of severity were defined according to the management needed: grade A, no specific intervention other than oral dietary restrictions; grade B, prolongation of hospital stay, nasoenteral nutrition with dietary restriction, total parenteral nutrition, octreotide, maintenance of surgical drains, or placement of new percutaneous drains; and grade C, need for other more invasive in-hospital treatment, intensive care unit admission, or mortality. Conclusion This classification and grading system for chyle leak after pancreatic resection allows for comparison of outcomes between series. As with the other the International Study Group on Pancreatic Surgery consensus statements, this classification should facilitate communication and evaluation of different approaches to the prevention and treatment of this complication.
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