Background
Initial recurrence mapping of resected pancreatic ductal adenocarcinoma (PDAC) could help in stratifying patient subpopulations for optimal postoperative follow‐up. The aim of this ...systematic review and meta‐analysis was to investigate the initial recurrence patterns of PDAC and to correlate them with clinicopathological factors.
Methods
MEDLINE and Web of Science databases were searched systematically for studies reporting first recurrence patterns after PDAC resection. Data were extracted from the studies selected for inclusion. Pooled odds ratios (ORs) and 95 per cent confidence intervals were calculated to determine the clinicopathological factors related to the recurrence sites. The weighted average of median overall survival was calculated.
Results
Eighty‐nine studies with 17 313 patients undergoing PDAC resection were included. The weighted median rates of initial recurrence were 20·8 per cent for locoregional sites, 26·5 per cent for liver, 11·4 per cent for lung and 13·5 per cent for peritoneal dissemination. The weighted median overall survival times were 19·8 months for locoregional recurrence, 15·0 months for liver recurrence, 30·4 months for lung recurrence and 14·1 months for peritoneal dissemination. Meta‐analysis revealed that R1 (direct) resection (OR 2·21, 95 per cent c.i. 1·12 to 4·35), perineural invasion (OR 5·19, 2·79 to 9·64) and positive peritoneal lavage cytology (OR 5·29, 3·03 to 9·25) were significantly associated with peritoneal dissemination as initial recurrence site. Low grade of tumour differentiation was significantly associated with liver recurrence (OR 4·15, 1·71 to 10·07).
Conclusion
Risk factors for recurrence patterns after surgery could be considered for specific surveillance and treatments for patients with pancreatic cancer.
Antecedentes
El mapeo del patrón de recidiva inicial tras la resección de un adenocarcinoma ductal pancreático (pancreatic ductal adenocarcinoma, PDAC) podría ayudar a estratificar subpoblaciones de pacientes para un seguimiento postoperatorio óptimo. El objetivo de esta revisión sistemática con metaanálisis fue investigar los patrones de recidiva inicial de PDAC y correlacionarlos con factores clínico‐patológicos.
Métodos
Se realizaron búsquedas sistemáticas en las bases de datos MEDLINE y Web of Science para seleccionar estudios que presentaran información sobre los patrones de recidiva inicial después de la resección del PDAC. Se extrajeron los datos de los estudios seleccionados para su inclusión en el metaanálisis. Se calcularon las razones de oportunidades agrupadas (pooled odds ratio, OR) y los i.c. del 95% para definir los factores clínico‐patológicos relacionados con las localizaciones de la recidiva. Se estimó el promedio ponderado de la mediana de la supervivencia global.
Resultados
Se incluyeron 89 estudios con 17.313 pacientes a los que se realizó una resección por PDAC. Las tasas medias ponderadas de las localizaciones de la recidiva inicial fueron del 20,8% para la locorregional, 26,5% para las hepáticas, 11,4% para el pulmón y 13,5% para la diseminación peritoneal. La mediana ponderada de supervivencia global fue de 19,8 meses (locorregional), 15,0 meses (hígado), 30,4 meses (pulmón) y 14,1 meses (diseminación peritoneal). El metaanálisis demostró que la resección R1 (inicial) (OR 2,21, i.c. del 95% 1,12–4,35), la invasión perineural (OR 5,19; i.c. del 95% 2,79–9,64) y la positividad de la citología del lavado peritoneal (OR 5,29; i.c. del 95% 3,03–9,25) se asociaron significativamente con la diseminación peritoneal como localización de recidiva inicial. El bajo grado de diferenciación tumoral se asoció significativamente con la recidiva hepática (OR 4,15; i.c. del 95%: 1,71‐10,07).
Conclusión
Se podrían tener en cuenta estos factores de riesgo de los patrones de recidiva tras la cirugía para realizar un seguimiento y tratamiento específicos en pacientes con cáncer de páncreas.
In this study, initial recurrence patterns and their prognosis after resection of pancreatic cancer were reviewed systematically, and a meta‐analysis undertaken of clinicopathological features of the primary tumour associated with each initial recurrence site. Based on the results, correctly predicting the site and prognosis of each recurrence could guide structured follow‐up after surgery and optimal treatment specific to recurrence site. LR, locoregional; NACRT, neoadjuvant chemoradiotherapy; CTx, chemotherapy; PeD, peritoneal dissemination.
Pattern related to survival
Background
The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias.
Methods
A ...systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence.
Results
A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference –1·79 (95 per cent c.i. –2·39 to –1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non‐industry‐funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01).
Conclusion
Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE: high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE: low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
Publication bias likely
Background Centralization of care to “centers of excellence” in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal ...cancer care in the United States. Methods The Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥10 resections/year) and hospitals (≥25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints. Results Among 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48–0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21–0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time. Conclusion This study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.
On September 28th, 2018, a powerful earthquake (M
w
7.5) struck the Island of Sulawesi in Indonesia. The earthquake was followed by a destructive and deadly tsunami that hit the Bay of Palu. A UNESCO ...international tsunami survey team responded to the disaster and surveyed 125 km of coastline along the Palu Bay up to the earthquake epicentre region. The team performed 78 tsunami runup and inundation height measurements throughout the surveyed coastline. Measured values reached 9.1 m for the runup height and 8.7 m for the inundation height, both at Benteng village. The survey team also identified ten large coastal sectors that collapsed into the sea of Palu Bay after the earthquake. The distribution of the measured tsunami data within Palu Bay exhibits a clear localised impact suggesting the contribution of secondary non-seismic local sources to the generation of the tsunami. Findings of the field reconnaissance are discussed to provide an insight into the remaining debated source of the Palu tsunami.
Background
Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess ...malnutrition associated with postoperative outcome.
Methods
Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.
Results
Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.
Conclusion
None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.
No score of use
Background
Preoperative α‐blockade in phaeochromocytoma surgery is recommended by all guidelines to prevent intraoperative cardiocirculatory events. The aim of this meta‐analysis was to assess the ...benefit of such preoperative treatment compared with no treatment before adrenalectomy for phaeochromocytoma.
Methods
A systematic literature search was undertaken in MEDLINE, Web of Science and CENTRAL without language restrictions. Randomized and non‐randomized comparative studies investigating preoperative α‐blockade in phaeochromocytoma surgery were included. Data on perioperative safety, effectiveness and outcomes were extracted. Pooled results were calculated as an odds ratio or mean difference with 95 per cent confidence interval.
Results
A total of four retrospective comparative studies were included investigating 603 patients undergoing phaeochromocytoma surgery. Mortality, cardiovascular complications, mean maximal intraoperative systolic and diastolic BP, and mean maximal intraoperative heart rate did not differ between patients with or without α‐blockade. The certainty of the evidence was very low owing to the inferior quality of studies.
Conclusion
This meta‐analysis has shown a lack of evidence for preoperative α‐blockade in surgery for phaeochromocytoma. RCTs are needed to evaluate whether preoperative α‐blockade can be abandoned.
Antecedentes
Todas las guías recomiendan el bloqueo alfa preoperatorio en la cirugía del feocromocitoma para prevenir eventos cardiocirculatorios intraoperatorios. El objetivo de este metaanálisis fue evaluar el beneficio de dicho tratamiento preoperatorio antes de la adrenalectomía por feocromocitoma en comparación con ningún tratamiento.
Métodos
Se realizó una búsqueda sistemática de la literatura en MEDLINE, Web of Science y CENTRAL sin restricciones de idioma. Se incluyeron estudios comparativos aleatorizados y no aleatorizados que investigaron el bloqueo alfa preoperatorio en la cirugía del feocromocitoma. Se extrajeron los datos en relación a la seguridad perioperatoria, la efectividad y los resultados. Los resultados agrupados se mostraron como razón de oportunidades (odds ratio, OR) o diferencia de medias (MD) con el correspondiente i.c. del 95%.
Resultados
Se incluyeron un total de cuatro estudios comparativos retrospectivos que analizaron a 603 pacientes sometidos a cirugía del feocromocitoma. La mortalidad, las complicaciones cardiovasculares, la media del valor máximo de la presión arterial sistólica y diastólica intraoperatoria y la media del valor máximo de la frecuencia cardíaca intraoperatoria no difirieron entre pacientes con o sin bloqueo. La certeza de la evidencia fue muy baja debido a la baja calidad de los estudios.
Conclusión
Este metaanálisis demuestra la falta de evidencia del bloqueo alfa preoperatorio en la cirugía del feocromocitoma. Se necesitan ensayos controlados aleatorizados para evaluar si se puede abandonar el bloqueo alfa preoperatorio.
Preoperative α‐blockade in phaeochromocytoma surgery is recommended by all guidelines to prevent intraoperative cardiocirculatory events. In this meta‐analysis, a total of four retrospective comparative studies were included investigating 603 patients undergoing phaeochromocytoma surgery. Mortality, cardiovascular complications, mean maximal intraoperative systolic and diastolic BP, and mean maximal intraoperative heart rate (HR) did not differ between patients with or without α‐blockade.
Time for an RCT?
Objective
To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT).
Background
Treatment of INP has ...changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies.
Methods
We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033
Results
Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval CI 0.31 0.10, 0.98) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR CI 0.31 0.10, 0.93), and pancreatic fistulae (OR CI 0.09 0.03, 0.28). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference CI − 7.86 days − 14.49, − 1.22). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate.
Conclusion
There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.
Background
Delayed gastric emptying (DGE) is a frequent complication after pylorus‐preserving pancreatoduodenectomy. Recent studies have suggested that resection of the pylorus is associated with ...decreased rates of DGE. However, superiority of pylorus‐resecting pancreatoduodenectomy was not shown in a recent RCT. This meta‐analysis summarized evidence of the effectiveness and safety of pylorus‐preserving compared with pylorus‐resecting pancreatoduodenectomy.
Methods
RCTs and non‐randomized studies comparing outcomes of pylorus‐preserving and pylorus‐resecting pancreatoduodenectomy were searched systematically in MEDLINE, Web of Science and CENTRAL. Random‐effects meta‐analyses were performed and the results presented as weighted odds ratios (ORs) or mean differences with their corresponding 95 per cent confidence intervals. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and non‐randomized studies.
Results
Three RCTs and eight non‐randomized studies with a total of 992 patients were included. Quantitative synthesis across all studies showed superiority for pylorus‐resecting pancreatoduodenectomy regarding DGE (OR 2·71, 95 per cent c.i. 1·48 to 4·96; P = 0·001) and length of hospital stay (mean difference 3·26 (95 per cent c.i. −1·04 to 5·48) days; P = 0·004). Subgroup analyses including only RCTs showed no significant statistical differences between the two procedures regarding DGE, and for all other effectiveness and safety measures.
Conclusion
Pylorus‐resecting pancreatoduodenectomy is not superior to pylorus‐preserving pancreatoduodenectomy for reducing DGE or other relevant complications.
No difference
Background
Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta‐analysis, the impact of ...perioperative PLT on PHLF and mortality was evaluated.
Methods
MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non‐randomized studies (MINORS) criteria. Meta‐analyses were performed using Mantel–Haenszel tests with a random‐effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals.
Results
Thirteen studies containing 5260 patients were included in the meta‐analysis. Two different cut‐off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater.
Conclusion
A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.
Low platelets, worse outcomes
Background
This study aimed to examine the effect of metabolic surgery on pre‐existing and future microvascular complications in patients with type 2 diabetes mellitus (T2DM) in comparison with ...medical treatment. Although metabolic surgery is the most effective treatment for obese patients with T2DM regarding glycaemic control, it is unclear whether the incidence or severity of microvascular complications is reduced.
Methods
A systematic literature search was performed in MEDLINE, Embase, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) with no language restrictions, looking for RCTs, case–control trials and cohort studies that assessed the effect of metabolic surgery on the incidence of microvascular diabetic complications compared with medical treatment as control. The study was registered in the International prospective register of systematic reviews (CRD42016042994).
Results
The literature search yielded 1559 articles. Ten studies (3 RCTs, 7 controlled clinical trials) investigating 17 532 patients were included. Metabolic surgery reduced the incidence of microvascular complications (odds ratio 0·26, 95 per cent c.i. 0·16 to 0·42; P < 0·001) compared with medical treatment. Pre‐existing diabetic nephropathy was strongly improved by metabolic surgery versus medical treatment (odds ratio 15·41, 1·28 to 185·46; P = 0·03).
Conclusion
In patients with T2DM, metabolic surgery prevented the development of microvascular complications better than medical treatment . Metabolic surgery improved pre‐existing diabetic nephropathy compared with medical treatment.
Surgery is better
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