Abstract Background Distal cholangiocarcinoma (DC) and pancreatic ductal adenocarcinoma (PDAC) are often managed as one entity, yet direct comparisons are lacking. Our aim was to utilize two, large, ...multi-institutional databases to assess treatment, pathologic, and survival differences between these diseases. Study Design Patients with DC and PDAC who underwent curative-intent pancreaticoduodenectomy from 2000-2015 at 13 institutions comprising the US Extrahepatic Biliary Malignancy and Central Pancreas Consortiums were included. Primary endpoint was disease-specific survival (DSS). Results Of 1463pts, 224(15%) were DC and 1239(85%) were PDAC. Compared to PDAC, DC patients were less likely to be margin-positive (19% vs 25%;p=0.005), lymph node (LN)-positive (55% vs 69%;p<0.001), and receive adjuvant therapy (57% vs 71%;p<0.001). Of DC patients treated with adjuvant therapy, 62% got gemcitabine alone and 16% got gemcitabine/cisplatin. DC was associated with improved median-DSS (40mos) compared to PDAC (22mos,p<0.001), which persisted on multivariable analysis (HR,0.65; 95%CI,0.50-0.84;p=0.001). LN-involvement was the only factor independently associated with decreased DSS for both DC and PDAC. DC/LN-positive patients had similar DSS as PDAC/LN-negative (p=0.74). Adjuvant therapy (chemotherapy+/-radiation) was associated with improved median-DSS for PDAC/LN-positive patients (21 vs 13mos;p=0.001), but not for DC patients (38 vs 40mos;p=0.62), regardless of LN status. Conclusions Distal cholangiocarcinoma and pancreatic ductal adenocarcinoma are distinct entities. DC has a favorable prognosis compared to PDAC, yet current adjuvant therapy regimens are only associated with improved survival in PDAC, not DC. Thus, treatment paradigms utilized for PDAC should not be extrapolated to DC, despite similar operative approaches, and novel therapies for DC should be explored.
Background Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; ...adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC. Study Design Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated. Results There were 1,130 patients who were divided into those having surgery alone (n = 392), ACT (n = 291), or ACRT (n = 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT. Conclusions This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC.
Abstract Background Controversy persists regarding the management of patients with IPMN. International consensus guidelines stratify patients into high risk, worrisome, and low risk categories. Study ...Design The medical records of 7 institutions were reviewed for patients that underwent surgical management of IPMN between 2000-2015. Results 324 patients were included in the analysis. 60.4% of patients had main-duct / mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, while invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n=136). 68.9% of patients with high risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/ IC. Multivariate analysis demonstrated that only one of three high risk features and two of seven worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI = 0.65-0.94) and 0.69 (95% CI= 0.39-0.91), respectively. In the absence of high risk features, HGD/ IC was still present in 57.4% of patients with two or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/ IC in a linear fashion (OR 1.39, 95% CI=1.08-1.80, p<0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.
Background As compared with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) affords improved perioperative outcomes. The role of LDP for patients with pancreatic ductal ...adenocarcinoma (PDAC) is not defined. Study Design Records from patients undergoing distal pancreatectomy (DP) for PDAC from 2000 to 2008 from 9 academic medical centers were reviewed. Short-term (node harvest and margin status) and long-term (survival) cancer outcomes were assessed. A 3:1 matched analysis was performed for ODP and LDP cases using age, American Society of Anesthesiologists (ASA) class, and tumor size. Results There were 212 patients who underwent DP for PDAC; 23 (11%) of these were approached laparoscopically. For all 212 patients, 56 (26%) had positive margins. The mean number of nodes (± SD) examined was 12.6 ±8.4 and 114 patients (54%) had at least 1 positive node. Median overall survival was 16 months. In the matched analysis there were no significant differences in positive margin rates, number of nodes examined, number of patients with at least 1 positive node, or overall survival. Logistic regression for all 212 patients demonstrated that advanced age, larger tumors, positive margins, and node positive disease were independently associated with worse survival; however, method of resection (ODP vs. LDP) was not. Hospital stay was 2 days shorter in the matched comparison, which approached significance (LDP, 7.4 days vs. ODP, 9.4 days, p = 0.06). Conclusions LDP provides similar short- and long-term oncologic outcomes as compared with OD, with potentially shorter hospital stay. These results suggest that LDP is an acceptable approach for resection of PDAC of the left pancreas in selected patients.
Background We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. Methods ...The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011–2013 ( n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. Results Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. Conclusion Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.
Introduction The modified Blalock–Taussig shunt (MBTS) is the most commonly created systemic–pulmonary shunt in neonates with cyanotic heart disease. Morbidity and mortality after MBTS is associated ...with several factors including age, pulmonary artery diameter and the baseline cardiac anatomy. The objective of this research was to describe the immediate and short-term follow-up results of MBTS in Pakistani neonates. Methods and Results A retrospective review of patient charts was done to select 22 neonatal cases of various types of cyanotic heart diseases who had undergone MBTS creation from 1999 to 2005. Clinical and echocardiographic data were collected. Patients were followed up on their post-operative visits. Twenty-two neonates, 14 males and 8 females, mean age 11.2 ± 6.9, underwent MBTS surgery during the six-year period of study. Pulmonary artery diameters were 3 ± 0.2 and 2.9 ± 0.2 for the right and left arteries, respectively. All patients received a 4 mm Gor-Tex shunt through a postero-lateral thoracotomy approach. The mean duration of post-operative mechanical ventilation was 3.9 ± 4.5 days. Three neonates (13.6%) died within one month of surgery while another three (13.6%) died after three months of surgery. Among these deaths, two were due to shunt occlusion/failure (9%) and the rest were due to non-cardiac causes. Another two patients underwent revision of surgery after shunt failure. Pulmonary atresia with intact interventricular septum was the most common cardiac anomaly in our series. Conclusions The mortality rate in neonates is highest during the first post-operative month. Shunt thrombosis and occlusion can be sudden and fatal therefore coagulation profile should be carefully monitored especially in the peri-operative period. PA-IVS was the most common anatomical variant in our limited experience and had high morbidity and mortality rate after surgery.
