David Petermann

Cost–benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy

Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost‐effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy.

Is tumour size an underestimated feature in the current TNM system for malignancies of the pancreatic head

BACKGROUND As the long-term survival of pancreatic head malignancies remains dismal, efforts have been made for a better patient selection and a tailored treatment. Tumour size could also be used for patient stratification. METHODS One hundred and fourteen patients underwent a pancreaticoduodenectomy for pancreatic adenocarcinoma, peri-ampullary and biliary cancer stratified according to: ≤20 mm, 21-34 mm, 35-45 mm and >45 mm tumour size. RESULTS Patients with tumour sizes of ≤20 mm had a N1 rate of 41% and a R1/2 rate of 7%. The median survival was 3.4 years. N1 and R1/2 rates increased to 84% and 31% for tumour sizes of 21-34 mm (P = 0.0002 for N, P = 0.02 for R). The median survival decreased to 1.6 years (P = 0.0003). A further increase in tumour size of 35-45 mm revealed a further increase of N1 and R1/2 rates of 93% (P < 0.0001) and 33%, respectively. The median survival was 1.2 years (P = 0.004). Tumour sizes >45 mm were related to a further decreased median survival of 1.1 years (P = 0.2), whereas N1 and R1/2 rates were 87% and 20%, respectively. DISCUSSION Tumour size is an important feature of pancreatic head malignancies. A tumour diameter of 20 mm seems to be the cut-off above which an increased rate of incomplete resections and metastatic lymph nodes must be encountered and the median survival is reduced.

Prediction of Complications After Pancreaticoduodenectomy: Validation of a Postoperative Complication Score.

Objectives Pancreatic surgery remains associated with important morbidity. Efforts are most commonly concentrated on decreasing postoperative morbidity, but early detection of patients at risk could be another valuable strategy. A simple prognostic score has recently been published. This study aimed to validate this score and discuss possible clinical implications. Methods From 2000 to 2012, 245 patients underwent a pancreaticoduodenectomy. Complications were graded according to the Dindo-Clavien Classification. The Braga score is based on American Society of Anesthesiologists score, pancreatic texture, Wirsung duct diameter, and blood loss. An overall risk score (0–15) can be calculated for each patient. Score discriminant power was calculated using a receiver operating characteristic curve. Results Major complications occurred in 31% of patients compared with 17% in Bragas data. Pancreatic texture and blood loss were independently statistically significant for increased morbidity. Areas under the curve were 0.95 and 0.99 for 4-risk categories and for individual scores, respectively. Conclusions The Braga score discriminates well between minor and major complications. Our validation suggests that it can be used as a prognostic tool for major complications after pancreaticoduodenectomy. The clinical implications, that is, whether postoperative treatment strategies should be adapted according to the patients individual risk, remain to be elucidated.

External assessment of the Early Mortality Risk Score in patients with adenocarcinoma undergoing pancreaticoduodenectomy

BACKGROUND Pancreaticoduodenectomies (PD) still have a substantial mortality rate. Recently, different scores have been published to predict the mortality risk pre-operatively after PD. This retrospective study was designed to perform an external assessment of an Early Mortality Risk Score (EMRS). METHODS From 2000 to 2012, all PD cases performed at our institution were documented. Only patients treated for pancreatic head adenocarcinomas were included. Survival time and EMRS (based on age, tumour size, tumour differentiation and comorbidities) were calculated for every patient. Relative risks (RR) of early death 9 and 12 months after PD were then calculated. RESULTS Of 270 PD for various aetiologies, 120 PD for adenocarcinomas were included. The median follow-up was 37 months, and the overall median survival was 19 months. EMRS of 4 showed a mortality RR of 5.1 at 9 months (P = 0.048) and of 4.5 at 12 months (P = 0.020). CONCLUSIONS EMRS of 4 is a predictor of tumour-related mortality at 9 and 12 months after PD for adenocarcinoma. The EMRS was externally assessed in our patient cohort and can be implemented in clinical practice. Clinical implications of this score still need to be studied.

Omental fibromatosis treated by laparoscopic wide surgical resection

The current report presents a case of an omental fibromatosis discovered incidentally in a 46-year-old woman with no particular medical history and few symptoms. A surgical biopsy was performed initially, and microscopic examination revealed myofibroblastic proliferation. After additional immunohistochemical and molecular analyses, omental fibromatosis was diagnosed. Omental fibromatosis, also called intra-abdominal desmoid, is a rare and benign tumour but can be locally aggressive. Majority of cases are asymptomatic, and difficult to diagnose based on clinical presentation and radiological investigation. Final diagnosis is usually made on histopathology and immunohistochemistry studies. Surgical wide excision is currently the treatment of choice.

Tumoral Venous Invasion after Distal Pancreatectomy: A Risk Factor for Recurrence

Background: Few data exist on postoperative outcomes of patients with pancreatic body-tail malignancies and tumoral venous invasion (VI). This study aimed at comparing survival and recurrence rate (RR) after distal pancreatectomy for adenocarcinoma in patients with and without tumoral VI. Methods: All consecutive distal pancreatectomies (2000–2015) were collected. Demographics and peri- and postoperative data were recorded. Survivals were calculated using Kaplan-Meier curves. Results: A total of 45 patients underwent distal pancreatectomies for malignancies, of which 33 patients had ductal adenocarcinomas and 2 had cystadenocarcinomas. Among these 35 adenocarcinomas, histological VI was found in 28 patients (80%). Characteristics and intraoperative data of patients with and without VI were similar. Complication rates were 15 of 28 (54%) in the VI group and 3 of 7 (43%) in the group without VI (p = 0.612). Five-year survival for the group with and without VI were 19 and 39% (p = 0.232), respectively. RR was 16 of 28 (57%) for the VI group and 1 of 7 (14%) for the group without VI (p = 0.042). Conclusion: VI did not have an effect on postoperative complications. Survivals were similar in case of VI or not. On the contrary, RR was higher in the VI group.

Surgery Indeed has an Important Role in Long-Term Outcome in Patients with Pancreatic Head Cancer by Zdravkovic et al.

We thank Zdravkovic et al. [1] for their comments on our article recently published in the World Journal of Surgery on the impact of postoperative complications on survival after pancreaticoduodenectomy for ductal adenocarcinoma. The key finding was that postoperative complications, especially if severe, had a negative impact on long-term survival. In particular, patients at increased risk for early tumor recurrence, e.g. after incomplete R1 resection, are concerned by the occurrence of severe complications. A meticulous prospective assessment of complications using a standardized classification system, e.g. the Dindo–Clavien classification, usually reveals a high complication rate, since minor complications are otherwise under-reported. Hence, our morbidity rates represent the ‘real world’ of pancreatic surgery. However, despite that the overall complication rate was 57 %, severe complications (higher than grade IIIb) occurred in only 16 %. The perpetual debate on prevention of delayed gastric emptying (DGE), pancreatic fistula, and postoperative hemorrhage was not taken as an outcome in our study. Contrary to the comment made, there is good evidence that pylorus-preserving pancreaticoduodenectomy (PPPD) is not related to higher DGE rates [2, 3]. The type of pancreaticojejunal anastomosis to best prevent pancreatic fistula is the subject of a large series of publications without any clear result favoring a particular technique. Further, the question of pancreaticogastrostomy versus pancreaticojejunostomy is not yet elucidated, as a recent meta-analysis shows no difference [4], whereas postoperative fistula was lower after pancreaticogastrostomy in two recent randomized controlled studies [5, 6]. The aim of the discussion about the impact of an R1 resection on long-term survival was to outline the multiplicity of the factors that could be taken into account to improve the results. Factors related to the tumor, such as tumor size, lymphovascular and perineural invasion, lymphatic node invasion, and differentiation might be balanced with the surgeon’s impact on the disease, i.e. resection margins and postoperative complications. Treatment of pancreatic ductal adenocarcinoma needs multidisciplinary care with knowledge of every parameter that could improve survival. R1 resection in the entire group of patients was correlated with worse outcomes (1.2 vs. 1.6 years, p = 0.037). In patients without severe postoperative complications, survival after R1 resection was 2.0 years compared with 1.4 years after R0 resection, but this was not significant (p = 0.27). Patients with severe postoperative complications and R1 resection had poorer outcomes (p = 0.0005). We can agree that results are based on a small number of patients, but even with small figures, statistical analysis showed strong significance. Moreover, to date, to the best of our knowledge, very few studies have specifically addressed the problem of postoperative complications and its impact on survival.

Diagnose und Therapie des Pankreaskarzinoms 2013

Um die immer noch ungunstige Prognose beim Pankreaskarzinom so weit wie moglich zu verbessern, gilt es, in interdisziplinarer Zusammenarbeit die Fortschritte aller einschlagigen Fachgebiete zu nutzen.

Prise en charge diagnostique et thérapeutique du cancer pancréatique en 2013

Une prise en charge multidisciplinaire, associant les progres de chaque specialite impliquee, est necessaire pour esperer ameliorer le pronostic encore limite du cancer du pancreas.