I.Q. Molenaar

Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality

The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in‐hospital mortality after PD in the Netherlands between 2004 and 2009.

Impact of centralization of pancreatic cancer surgery on resection rates and survival

Centralization of pancreatic surgery has been shown to reduce postoperative mortality. It is unknown whether resection rates and survival have also improved. The aim of this study was to analyse the impact of nationwide centralization of pancreatic surgery on resection rates and long‐term survival.

Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer

Locally advanced pancreatic cancer (LAPC) is associated with a very poor prognosis. Current palliative (radio)chemotherapy provides only a marginal survival benefit of 2–3 months. Several innovative local ablative therapies have been explored as new treatment options. This systematic review aims to provide an overview of the clinical outcomes of these ablative therapies.

Systematic review of five feeding routes after pancreatoduodenectomy

Current European guidelines recommend routine enteral feeding after pancreato‐duodenectomy (PD), whereas American guidelines do not. The aim of this study was to determine the optimal feeding route after PD.

Prolonged portal triad clamping during liver surgery for colorectal liver metastases is associated with decreased time to hepatic tumour recurrence

AIMS The aim of this study was to evaluate the oncological outcome of portal triad clamping during hepatectomy in colorectal cancer patients. METHODS 160 patients with colorectal liver metastases underwent a partial hepatectomy with curative intent. Data were collected in a prospective database and were retrospectively analyzed for time to liver recurrence (TTLiR) and time to overall recurrence (TTR). The prognostic significance of portal triad clamping of any type and severe ischemia due to prolonged portal triad clamping was determined by Cox regression models. RESULTS TTLiR was reduced after clamping of any type, although not statistically significant (p=0.061). Severe ischemia due to prolonged portal triad clamping significantly decreased TTLiR (p=0.022), but not TTR. Furthermore, severe ischemia independently predicted TTLiR in a multivariable analysis (p=0.038). CONCLUSIONS Severe ischemia due to prolonged portal triad clamping during hepatic resection for colorectal liver metastases appears to be associated with decreased TTLiR. Further research remains necessary to determine the causative effect of prolonged vascular clamping on liver tumour recurrence.

FOLFIRINOX in Locally Advanced and Metastatic Pancreatic Cancer: A Single Centre Cohort Study

Introduction: FOLFIRINOX is emerging as new standard of care for fit patients with locally advanced pancreatic cancer (LAPC) and metastatic pancreatic cancer (MPC). However, some of the physicians are reluctant to use FOLFIRINOX due to high toxicity rates reported in earlier studies. We reviewed our experience with FOLFIRINOX in LAPC and MPC, focussing on dose adjustments, toxicity and efficacy. Methods: We reviewed all patients with LAPC or MPC treated with FOLFIRINOX in our institution between April 2011 and December 2015. Unresectability (stage III and IV) was determined by the institutions multidisciplinary team for pancreatic cancer. Results: Fifty patients (18 LAPC and 32 MPC) were enrolled, with a median age of 55 years (IQR 49-66) and WHO performance status of 0/1. FOLFIRINOX was given as first-line treatment in 82% of patients. Dose modifications were applied in 90% of patients. The median number of completed cycles was 8 (IQR 5-9). Grade 3-4 toxicity occurred in 52% and grade 5 toxicity in 2%. The response rate was 25% (12% in LAPC, 32% in MPC). Median overall survival and progression-free survival were 14.8 and 10.3 months in LAPC, and 9.0 and 5.9 months in MPC, respectively. Overall 1- and 2-year survival was 65% and 10% in LAPC and 40% and 5% in MPC. Within the LAPC group, 6 patients (33%) underwent local ablative therapy and 1 patient (6%) a resection, leading to a median survival of 21.8 months. Conclusion: FOLFIRINOX treatment with nearly routine dose modification was associated with acceptable toxicity rates, relatively high response rates and an encouraging overall survival.

Health‐related quality of life after pancreatic resection for malignancy

Health‐related quality of life (QoL) is of major importance in pancreatic cancer, owing to the limited life expectation. The aim of this prospective longitudinal study was to describe QoL in patients undergoing resection for pancreatic or periampullary malignancy.

Hospital of diagnosis and likelihood of surgical treatment for pancreatic cancer

Surgical resection for pancreatic cancer offers the only chance of cure. Assessment of the resectability of a pancreatic tumour is therefore of great importance. The aim of the study was to investigate whether centre of diagnosis influences the likelihood of surgery and whether this affects long‐term survival.

DPC4, P53 and MTAP expression in patients with locally advanced and metastastic pancreatic cancer

prominent, is associated with a parenchymal component. The prognosis of these tumors is unknown. It is occassionaly difficult to differentiate based on imaging between pancreatic lesions with prominent intraductal growth pattern. Conclusion: Preoperative diagnosis of P-NET with intraductal growth remains difficult. NET should be kept in mind in the differential diagnosis of intraductal lesions because its therapeutical implications.

Authors' reply: Systematic review of five feeding routes after pancreatoduodenectomy (Br J Surg 2013; 100: 589–598)

Sir We thank Professor Bozzetti for his comments on our review. Although data on the impact of early oral feeding (EOF) on the length of stay after pancreatoduodenectomy were indeed scarce at the time of our review, since then two new cohort studies have confirmed the assumed positive impact of EOF in enhanced recovery programmes1,2. In addition, the recent enhanced recovery after surgery (ERAS) guidelines provide quite a clear definition of what EOF after pancreatic surgery entails3. Obviously, some patients are unable to meet the desired targets, for instance owing to complications. The suggestion that the beneficial effect of EOF may be explained simply by an early ‘function test’ of the gastrointestinal tract is probably true. However, we consider this a positive asset of EOF. It may be the exact reason why patients receiving EOF may return to a normal oral intake more quickly than they would if they received routine (par)enteral nutrition . EOF has the benefit of challenging the gastrointestinal tract, without the disadvantages associated with enteral feeding strategies; these include the well known, albeit rare, risk of potentially lethal complications of catheter jejunostomies4, as we have unfortunately found ourselves confronted with as well5. Finally, to our knowledge, the suggested negative effects of EOF on a pancreatogastric anastomosis have never been demonstrated. In our opinion, EOF is a well defined strategy without proven risks and may therefore be considered the preferred routine feeding strategy after pancreatoduodenectomy. Obviously, for selected patients (for example those with preoperative malnutrition, gastric outlet obstruction or a complicated postoperative course) tailored nutritional support is indicated. A. Gerritsen1, I. Q. Molenaar1 and M. G. Besselink1,2 Departments of Surgery, 1University Medical Centre Utrecht, Utrecht, and 2Academic Medical Centre, Amsterdam, The Netherlands (e-mail: m.g.besselink@amc.nl) DOI: 10.1002/bjs.9151