Background
The aim of this study was to assess the perioperative and pathologic outcomes of robotic distal pancreatectomy compared with a laparoscopic approach.
Methods
A total of 121 robotic distal ...pancreatectomies and 992 laparoscopic distal pancreatectomies were retrospectively evaluated, comparing the demographic, perioperative and pathologic outcomes. After 1:2 propensity score matching (PSM) with 11 demographic variables, the factors were analysed again.
Results
Following PSM, 104 robotic distal pancreatectomy patients were compared with 208 laparoscopic distal pancreatectomy patients. The operation time and proportion of spleen preservation were not different between the groups. The rates of open conversion were lower, whereas the hospital costs were higher in the robotic group. Other perioperative outcomes and pathologic factors did not differ between the groups.
Conclusions
Although robotic distal pancreatectomy is more expensive, this operation is feasible, with a higher probability of proceeding with the planned operation and with low open conversion rate.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
To identify chronologic changes in clinical and survival features of pancreatic ductal adenocarcinoma based on diagnosis and treatment strategy development since 2000.
Among 2,029 patients enrolled ...in this study, 746 and 1,283 were treated between 2000 and 2009 (group 1) and between 2010 and 2016 (group 2), respectively. We used patient clinicopathologic, biologic, and molecular factors to assess the prognostic factors.
Group 2 had a better survival outcome than group 1 (median survival time: 24.9 versus 18.4 months; 5-year survival rate: 27.6% versus 22.3%). The tendency for early diagnosis (lower CA19-9 levels, smaller size, and earlier T stage), use of neoadjuvant chemotherapy, decreased morbidity, early recovery (lesser hospital stay and more minimally invasive surgery), and standardization of surgical techniques appeared to improve patient survival. Multivariable analysis for prognosis revealed that tumor biologic factors (increased preoperative serum CA19-9 level, tumor size, tumor differentiation, N stage, and presence of lymphovascular invasion), operational factors (status of the resection margin, type of operation, and year of operation), and genetic factors (K-ras mutations) correlated with patient survival.
Early diagnosis and combined efforts, such as neoadjuvant chemotherapy and an established system of patient care, have gradually enhanced patient survival after operative resection for pancreatic ductal adenocarcinoma. Hence, multiplex prognostic parameters could provide additional information for improved prognostic estimation of pancreatic cancer exhibiting heterogeneous results.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Stereotactic body radiation therapy (SBRT) is a promising treatment modality for locally advanced pancreatic cancer (LAPC). We evaluated the clinical outcomes of SBRT in patients with LAPC.
We ...retrospectively analyzed the medical records of patients with LAPC who underwent SBRT at our institution between April 2011 and July 2016. Fiducial markers were implanted using endoscopic ultrasound guidance one week prior to 4-dimensional computed tomography (CT) simulation and daily cone beam CT was used for image guidance. Patients received volumetric modulated arc therapy or intensity modulated radiotherapy using respiratory gating technique. A median dose of 28 Gy (range, 24-36 Gy) was given over four consecutive fractions delivered within one week. Survival outcomes including freedom from local disease progression (FFLP), progression-free survival (PFS), and overall survival (OS) were analyzed. Acute and late toxicities related to SBRT were assessed.
A total of 95 patients with LAPC were analyzed, 52 of which (54.7%) had pancreatic head cancers. Most (94.7%) had received gemcitabine-based chemotherapy. The 1-year FFLP rate was 80.1%. Median OS and PFS were 16.7 months and 10.2 months, respectively; the 1-year OS and PFS rates were 67.4% and 42.9%, respectively. Among 79 patients who experienced failure, the sites of first failures were isolated local progressions in 12 patients (15.2%), distant metastasis in 55 patients (69.6%), and both in 12 patients (15.2%). Seven patients (7.4%) were able to undergo surgical resection after SBRT and four had margin-negative resections. Three patients (3.2%) had grade 3 nausea/vomiting during SBRT, and late grade 3 toxicity was observed in another three patients.
LAPC patients who received chemotherapy and SBRT had favorable FFLP and OS with minimal treatment-related toxicity. The most common pattern of failure was distant metastasis, which warrants further studies on the optimal scheme of chemotherapy and SBRT.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Management of early‐stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication ...of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder.
Methods
The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery.
Results
A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence‐free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology.
Conclusions
Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.
Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence‐free survival and overall survival compared to those with gallbladder cancer on the fundal end. Our results suggest that gallbladder cancers on the cystic ductal end were associated with worse postoperative oncologic outcomes compared with gallbladder cancers on the fundal end.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
In surgery for perihilar cholangiocarcinoma (PHCC), it is still controversial as to whether additional resection of the bile duct is needed on high grade (HG) biliary intraepithelial ...neoplasia (BilIN) margin.
Methods
Patients who underwent surgery for PHCC with curative intent between 2001 and 2015 were stratified by resection margin, and were analyzed comparing the clinical outcomes.
Results
Of the 306 study participants, 217 patients had negative margins (R0), 18 patients had HG BilIN, and 71 patients had positive margins (R1). The median overall survival was 36.0 months in the R0 group, 41.0 months in the HG BilIN group, and 25.0 months in the R1 group while overall survival rates at 5 years were 34.5% in the R0 group, 44.4% in the HG BilIN group, and 21.0% in the R1 group. The median disease‐free survival was 15.0 months in the R0 group, 16.5 months in the HG BilIN group, and 12.0 months in the R1 group.
Conclusions
Although the HG BilIN group had neoplasia with malignant potential, survival and recurrence outcomes were comparable to those of the R0 group, which suggests that no additional resection is needed when the maximal bile duct margin in PHCC surgery contains HG BilIN.
Highlight
In surgery for perihilar cholangiocarcinoma, additional resection when the margin contains high grade biliary intraepithelial neoplasia (HG BilIN) remains controversial. Investigating the prognostic implications, Shin and colleagues found comparable survival and recurrence outcomes in patients with HG BilIN margins and those with negative margins, obviating the need for additional resection.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
The association of resection margin status with recurrence and survival after pancreatectomy for pancreas ductal adenocarcinoma (PDAC) remains controversial. The aim of this study was to ...identify the effect of R1 resection on recurrence pattern and survival after distal pancreatectomy for left‐sided PDAC.
Methods
Patients who underwent distal pancreatectomy for PDAC at two high‐volume institutions between January 2010 and December 2017 were retrospectively reviewed. Perioperative characteristics, pathological outcomes, recurrence pattern, and survival data were collected to compare R0 resection and R1 resection.
Results
Among 558 patients who underwent distal pancreatectomy for PDAC, 158 patients (28.3%) showed R1 resection margin. R1 patients were associated with large tumor size (3.3 cm vs. 3.7 cm, p = .006) and lower number of positive lymph nodes (1.3 vs. 2.0, p = .001). Median overall survival (37.3 months vs. 20.1 months, p < .001) and recurrence‐free survival (14.6 months vs. 6.9 months, p < .001) significantly differed between the R0 and R1 groups. Disease recurrence patterns were not statistically different between the two groups (p = .182). Among the recurrence patterns, peritoneal carcinomatosis had the shortest recurrence‐free survival (5.6 months, p < .05) and overall survival (13.6 months, p < .05) compared with all other recurrence patterns.
Conclusions
R1 resection margin after distal pancreatectomy was associated with poor survival and early recurrence. There is no significant difference in recurrence pattern between R0 and R1. Among the recurrence patterns, peritoneal carcinomatosis showed the worst prognosis.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Postoperative pancreatic fistula is a life-threatening complication with an unmet need for accurate prediction. This study was aimed to develop preoperative artificial intelligence-based prediction ...models. Patients who underwent pancreaticoduodenectomy were enrolled and stratified into model development and validation sets by surgery between 2016 and 2017 or in 2018, respectively. Machine learning models based on clinical and body composition data, and deep learning models based on computed tomographic data, were developed, combined by ensemble voting, and final models were selected comparison with earlier model. Among the 1333 participants (training, n = 881; test, n = 452), postoperative pancreatic fistula occurred in 421 (47.8%) and 134 (31.8%) and clinically relevant postoperative pancreatic fistula occurred in 59 (6.7%) and 27 (6.0%) participants in the training and test datasets, respectively. In the test dataset, the area under the receiver operating curve AUC (95% confidence interval) of the selected preoperative model for predicting all and clinically relevant postoperative pancreatic fistula was 0.75 (0.71-0.80) and 0.68 (0.58-0.78). The ensemble model showed better predictive performance than the individual ML and DL models.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
This study investigated survival differences following intra‐operative frozen‐section examination of bile duct resection margins and final longitudinal margin status (LMS) in distal bile ...duct cancer (BDC).
MethodsOne hundred and ninety‐three patients underwent Whipple's operation for curative resection of distal BDC from 2008 to 2016. Patients were sorted into two and three groups according to LMS of the frozen‐sections and the final pathological specimen results: R0 on first bile duct resection (primary R0), R0 after additional resection (secondary R0), and no evidence of residual carcinoma (FR0), carcinoma in situ or high‐grade dysplasia (FR1‐CIS/HGD), or invasive carcinoma (FR1‐INV). Survival and prognostic factors according to LMS were analyzed.
Results
The final R0 ratio increased from 82.3% to 90.1% through additional resection. The 5‐year overall survival (OS) of primary and secondary R0 were 60.8%, 46.1% (P = 0.969). And disease‐free survival of primary and secondary R0 were 54.6%, 54.9% (P = 0.903). The 5‐year OS after FR0, FR1‐CIS/HGD, FR1‐INV were 59.3%, 59.5%, 14.3% (P = 0.842). LMS of the bile duct was an independent prognostic factor by multivariable analyses.
Conclusions
If R0 of final LMS was achieved, it would help to improve survival regardless of R0 through additional resection. And, it should be avoided remaining invasive cancer at the longitudinal margin whenever possible.
Highlight
Comparing the longitudinal margin status in distal bile duct cancer confined to the intra‐pancreatic portion, the authors revealed that there were no significant differences in overall survival and disease‐free survival among cases with no residual tumor, high‐grade dysplasia and carcinoma in situ on both frozen‐section and final pathological examination.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background/Purpose
Laparoscopic pancreaticoduodenectomy (PD) with major vein resection is a challenging procedure. Herein, we evaluated the feasibility and safety of laparoscopic vein resection in ...pancreatic head cancer with portal vein/superior mesenteric vein (PV/SMV) invasion, and compared the survival rate following laparoscopic surgery with that following open surgery.
Methods
We retrospectively reviewed the electronic medical records of all patients with pancreatic head cancer who underwent surgery performed by a single surgeon from January 2015 to December 2017. Kaplan–Meier curves were plotted to compare the disease‐free survival, while Cox‐proportional hazard models were used to analyze prognostic factors for survival.
Results
Among 76 patients, 63 underwent open PD and 13 underwent laparoscopic PD with PV/SMV resection. There was no significant difference in the rate of complications, including portal vein stenosis and portal vein thrombus, recurrence of tumors, or pathological outcomes after surgery between the groups. There was also no significant difference in disease‐free survival (p = .803) between the two groups. Additionally, the surgical method was not an independent prognostic factor for disease‐free survival.
Conclusions
Laparoscopic PD with major vein resection can be feasibly performed in select patients with abutment and focal narrowing of the PV/SMV in pancreatic head cancer.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Afferent loop obstruction (ALO) is a rare mechanical complication of pancreaticoduodenectomy (PD) and is associated with a high rate of morbidity and mortality.
Methods
Data from patients ...who underwent PD between May 2007 and July 2017 at a single large‐volume center were retrospectively reviewed.
Results
Of the 3,223 patients who underwent PD, 67 developed ALO. More patients in the laparoscopic PD (LPD) group had developed ALO due to internal herniation than did those in the open PD (OPD) group (46.2 vs. 4.7%, P < 0.001). Patients in the LPD group also showed earlier occurrence of ALO (ALO occurrence within 60 days: 76.9 vs. 22.2%, P < 0.001) and more frequent requirement for surgical treatment (76.9 vs. 18.9%, P < 0.001) than did those in the OPD group.
Conclusions
The characteristics of ALO were significantly different between patients who had received LPD and OPD. The most common cause of ALO in the LPD group was internal herniation occurring in the early postoperative period. Internal herniation following LPD may be prevented by routine closure of mesocolic window and should be treated by emergency surgery if it occurs.
Highlight
Laparoscopic and open pancreaticoduodenectomy groups differed significantly in terms of the characteristics of afferent loop obstruction (cause, interval until diagnosis, rate of reoperation). Song and colleagues concluded that closure of the mesocolic window by suturing between the jejunal limb and mesocolon may help prevent afferent loop obstruction following laparoscopic pancreaticoduodenectomy.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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