Venous resection for adenocarcinoma of head of pancreas: Does extent of portal vein resection affect outcomes?

BackgroundVenous resection with pancreaticoduodenectomy (PD) increases resectability rates in patients with adenocarcinoma of head of pancreas. The effect of extent of portal vein resection on perioperative morbidity and mortality is less clear. This retrospective cohort study compares results of PD with and without venous resection and explores the influence of extent of vein resection on perioperative morbidity and mortality.MethodsTotal 96 patients underwent standard PD (PD) and 20 patients had en bloc venous resections (VR). VR group was divided into segmental (VR-S) (6/20 patients) and tangential (VR-T) (14/20 patients) groups based on segmental or tangential type of venous resections. The groups were compared for morbidity, mortality and survival.ResultsPD and VR groups had comparable perioperative morbidity (p = 0.140) and mortality (p = 0.358) with a significantly higher operative time in VR (p < 0.001). Perioperative morbidity and mortality were similar in VR-S and VR-T groups (p = 0.690 and p = 0.157 respectively). Operative time and estimated blood loss were significantly higher in VR-S group over VR-T (p = 0.019 and p = 0.002 respectively). Median survival was similar for PD and VR (15 and 15.5 moths respectively; p = 0.278) and VR-S and VR-T groups (17 and 12.5 months respectively; p = 0.550). Expected blood loss and operative time were found to be independent predictors of morbidity.ConclusionsVenous resection with PD is associated with morbidity, mortality and overall survival comparable to that after standard resection. The extent of venous resection does not seem to affect perioperative morbidity and mortality.     

Conditional survival after surgery for metastatic tumors of the spine: does prognosis change over time?

Purpose

Conditional survival (CS) provides a dynamic prediction of patient survival by incorporating the time an individual has already survived given their disease specific characteristics. The objective of the current study was to estimate CS among patients after surgery for spinal cord compression or spinal instability, as well as stratify CS according to relevant patient- and disease-related characteristics.

Methods

The clinical outcomes of 361 patients undergoing surgical management of metastatic spinal tumors were retrospectively analyzed. Stratification of this cohort according to disease and surgery-specific characteristics allowed for univariate and multivariate statistical analyses of our study population. Observed overall and conditional survival estimates were calculated by the Kaplan–Meier method.

Results

12-month conditional survival in patients undergoing surgical management of metastatic spine tumors increased from 57% at baseline to 70% at 24 months following spine surgery. Overall survival (OS) was influenced by CCI grade, Katagiri tumor type, presence of lung metastasis, type of spine surgery, presence of postoperative systemic therapy and ambulatory status at follow-up. Analyses of OS and CS by prognostic strata were similar with exception of stratification by surgery type. Differences in survival between strata tend to converge over time. Unfavorable factors for OS appear to be less relevant after a period of 24 months following spine surgery.

Conclusion

Patients after surgery for metastatic tumors of the spine can expect a positive trend in conditional survival as survivorship increases. Even patients with a more severe disease can be encouraged with gains in conditional survival over time.

Level of evidence

Level IV (retrospective cohort study).

     

Is extended resection for adenocarcinoma of the body or tail of the pancreas justified?

Patients with body or tail tumors of the pancreas often have contiguous organ involvement or portalsplenic confluence adherence requiring extensive resection in order to obtain grossly negative margins. The aim of this study was to determine whether long-term survival is possible after contiguous organ or portal vein resection in patients with adenocarcinoma of the body or tail of the pancreas. Between 1983 and 2000, a total of 513 patients with adenocarcinoma of the body or tail of the pancreas were identified from a prospective database. Distal pancreatectomy with or without splenectomy was performed in 57 patients (11%). Extended resection was necessary in 22 patients (39%): 14 (64%) for contiguous organ involvement and eight (36%) for portal vein resection Estimated blood loss, blood transfused, and length of hospital stay were significantly greater in patients requiring extended resection compared to standard resection (P = 0.02, P = 0.01, and P = 0.02, respectively). Median follow-up for patients still alive was 84 months (range 40 to 189 months). Median survival following resection was 15.9 months compared to 5.8 months in patients who were not resected (P < 0.0001). Actual 5- and 10-year survival rates were 22% and 18%, respectively, following extended resection, 8% and 8% following standard resection, and 0% and 0% if no resection was attempted because of locally unresectable disease. Patients undergoing extended resection for adenocarcinoma of the pancreatic body or tail have long-term survival rates similar to those for patients undergoing standard resection; they also have markedly improved long-term survival compared to those who are not considered resectable because of locally advanced disease. Extended distal pancreatectomy is justified in this group of patients. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003. Supported by a grant from the Stern Foundation.     

Slight head extension: does it change the sagittal cervical curve?

It is commonly believed that slight flexion/extension of the head will reverse the cervical lordosis. The goal of the present study was to determine whether slight head extension could result in a cervical kyphosis changing into a lordosis. Forty consecutive volunteer subjects with a cervical kyphosis and with flexion in their resting head position had a neutral lateral cervical radiograph followed immediately by a lateral cervical view taken in an extended head position to level the bite line. Subjects were patients at a spine clinic in Elko, Nevada. All radiographs were digitized. Global and segmental angles of the cervical curve were compared for any change in angle due to slight extension of the head. The average extension of the head required to level the bite line was 13.9 degrees. This head extension was not substantially correlated with any segmental or global angle of lordosis. Subjects were categorized into those requiring slight head extension (0 degree-13.9 degrees) and those requiring a significant head extension (> 13.9 degrees). In the slight head extension group, the average change in global angle between posterior tangents on C2 and C7 was 6.9 degrees, and 80% of this change occurred in C1-C4. In the significant head extension group, the average change in global angle between posterior tangents on C2 and C7 was 11.0 degrees, and the major portion of this change occurred in C1-C4. Out of 40 subjects, only one subject, who was in the significant head extension group and had only a minor segmental kyphosis, changed from kyphosis to lordosis. The results show that slight extension of the head does not change a reversed cervical curve into a cervical lordosis as measured on lateral cervical radiographs. Only small extension angle changes (mean sum = 4.8 degrees) in the upper cervical segments (C2-C4) occur in head extension of 14 degrees or less.     

Pancreaticoduodenectomy for periampullary cancer: does the tumour entity influence perioperative morbidity and long-term outcome?

Background: Malignant tumours of the periampullary region include ductal adenocarcinoma of the pancreas (Pan-Ca), distal bile duct cancer (DBDC) and adenocarcinoma of the ampulla (Amp-Ca). The present retrospective clinical study was designed to evaluate the influence of tumour entity on postoperative complications and identify risk factors predicting survival and morbidity.

Methods: We retrospectively analysed data from all patients who underwent pancreatic resection for periampullary cancer with curative intent (R0 or R1). Demographic data, risk factors, perioperative complications and survival rates for the different subtypes were assessed.

Results: A total of 225 patients with periampullary cancer were identified: 124 (55.1%) had Pan-Ca, 55 (24.4%) had DBDC and 46 had (20.4%) Amp-Ca. Sixty-nine patients (30.7%) had major complications (grade IIIb–V). Patients with DBDC had significantly more grade C pancreatic fistulas. Univariate analysis revealed male gender, BMI >30, R1-status, and low-grade tumour differentiation as risk factors for major complications. Overall in-hospital-mortality was 6.7%.

Conclusions: Further research will be needed to implement more individualized therapy.     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.     

Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving?

OBJECTIVE: The authors review their recent experience with resected pancreatic ductal adenocarcinoma. SUMMARY BACKGROUND DATA: Ductal adenocarcinoma of the pancreas has traditionally had a 5-year survival rate less than 10% after curative resection. Recently, several groups have reported markedly improved 5-year survival rates (approaching 25%) for patients undergoing curative resection. METHODS: Institutional experience with 186 consecutive patients (1981-1991) with pathologic diagnoses of ductal adenocarcinoma undergoing pancreatic resection was reviewed. Histologic specimens of all 3-year survivors (n = 31) were re-reviewed by two pathologists, one internal and one external; nonductal pancreatic cancers then were excluded. RESULTS: After histologic re-review, 12 patients did not have ductal adenocarcinoma, leaving a total of 174 patients for analysis (102 men, 72 women; mean age 63 years, range 34-82 years). Mean follow-up was 22 months (range 4-109). Classical pancreaticoduodenectomy was performed in 71%, pylorus-preserving resection in 9%, and total pancreatectomy in 20%. Hospital mortality was 3%. Twenty-eight patients (16%) had macroscopically incomplete resections; 98 (56%) had lymph node metastases within the resected specimens, and 21 patients (12%) had extensive perineural invasion. Overall actuarial 5-year survival was 6.8%. Five-year survival was greater for node-negative versus node-positive patients (14% vs. 1%, p < 0.001), and for smaller (< 2 cm) versus larger tumors (20% vs. 1%, p < 0.001). The 5-year survival for the subset of patients with negative nodes and no perineural or duodenal invasion (69 patients) was 23% (p < 0.001). Mean survival of the 12 excluded patients was 53 +/- 7 months compared with 17.5 +/- 1 months in the 174 patients with ductal pancreatic cancer. CONCLUSIONS: Five-year survival for patients undergoing pancreatic resection for lesions deemed to be clinically "curable" intraoperatively and histologically reviewed/confirmed to be ductal adenocarcinoma of the pancreas is approximately 7%. Survival is greater (23%) in the subset of patients with negative nodes and no duodenal or perineural invasions. Pathologic review of all patients with pancreatic ductal cancer adenocarcinoma is mandatory if survival data are to be meaningful.     

Management of pancreatic head adenocarcinoma: From where to where?

Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.     

Trials of vaccines for pancreatic ductal adenocarcinoma: Is there any hope of an improved prognosis?

Pancreatic tumors are chemoresistant and malignant, and there are very few therapeutic options for pancreatic cancer, as the disease is normally diagnosed at an advanced stage. Although attempts have been made to develop vaccine therapies for pancreatic cancer for a couple of decades, none of the resultant protocols or regimens have succeeded in improving the clinical outcomes of patients. We herein review vaccines tested within the past few years, including peptide, biological and multiple vaccines, and describe the three sets of criteria used to evaluate the therapeutic activity of vaccines in solid tumors.     

Resected adenocarcinoma of the pancreas— 616 patients: Results, outcomes, and prognostic indicators

This large-volume, single-institution review examines factors influencing long-term survival after resection in patients with adenocarcinoma of the head, neck, uncinate process, body, or tail of the pancreas. Between January 1984 and July 1999 inclusive, 616 patients with adenocarcinoma of the pancreas underwent surgical resection. A retrospective analysis of a prospectively collected database was performed. Both univariate and multivariate models were used to determine the factors influencing survival. Of the 616 patients, 526 (85%) underwent pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas, 52 (9%) underwent distal pancreatectomy for adenocarcinoma of the body or tail, and 38 (6%) underwent total pancreatectomy for adenocarcinoma extensively involving the gland. The mean age of the patients was 64.3 years, with 54% being male and 91% being white. The overall perioperative mortality rate was 2.3%, whereas the incidence of postoperative complications was 30%. The median postoperative length of stay was 11 days. The mean tumor diameter was 3.2 cm, with 72 % of patients having positive lymph nodes, 30% having positive resection margins, and 36% having poorly differentiated tumors. Patients undergoing distal pancreatectomy for left-sided lesions had larger tumors (4.7 vs. 3.1 cm, P <0.0001), but fewer node-positive resections (59% vs. 73%, P = 0.03) and fewer poorly differentiated tumors (29% vs. 36%, P<0.001), as compared to those undergoing pancreaticoduodenectomy for right-sided lesions. The overall survival of the entire cohort was 63% at 1 year and 17% at 5 years, with a median survival of 17 months. For right-sided lesions the 1- and 5-year survival rates were 64% and 17%, respectively, compared to 50% and 15% for left-sided lesions. Factors shown to have favorable independent prognostic significance by multivariate analysis were negative resection margins (hazard ratio [HR] = 0.64, confidence interval [CI] = 0.50 to 0.82, P = 0.0004), tumor diameter less than 3 cm (HR = 0.72, CI = 0.57 to 0.90, P = 0.004), estimated blood loss less than 750 ml (HR = 0.75, CI = 0.58 to 0.96, P = 0.02), well/moderate tumor differentiation (HR = 0.71, CI = 0.56 to 0.90, P = 0.005), and postoperative chemoradiation (HR = 0.50, CI = 0.39 to 0.64, P } < 0.0001). Tumor location in head, neck, or uncinate process approached significance in the final multivariate model (HR = 0.60, CI = 0.35 to 1.0, P = 0.06). Pancreatic resection remains the only hope for long-term survival in patients with adenocarcinoma of the pancreas. Completeness of resection and tumor characteristics including tumor size and degree of differentiation are important independent prognostic indicators. Adjuvant chemoradiation is a strong predictor of outcome and likely decreases the independent significance of tumor location and nodal status. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Retroperitoneal margin involvement by adenocarcinoma of the caecum and ascending colon: what does it mean?

Objective Circumferential margin involvement (CRM) is a powerful predictor of local recurrence, distant metastasis and patient survival in rectal cancer. In this study, we aimed to determine the frequency of retroperitoneal margin involvement in right colon cancer and describe its relationship to tumour stage and outcome of surgical treatment. Method Two hundred and twenty‐eight consecutive resections for adenocarcinoma of the ascending colon and caecum were identified between 1998 and 2006. Tumour involvement of the posterior retroperitoneal surgical resection margin (RSRM) was recorded and correlated with tumour stage, grade and clinical outcome. RSRM positive patients were compared with CRM positive rectal tumours resected in the same surgical unit. Results Nineteen of 228 right hemicolectomies (8.4%) showed tumour involvement of the RSRM (defined as ≤ 1 mm). Approximately half of the RSRM positive patients underwent palliative resections because of synchronous distant metastases. Out of nine ‘potentially curative’ resections where the RSRM was involved, five patients subsequently developed metastatic recurrence and two isolated local recurrence. RSRM positivity was associated with advanced tumour stage and more extensive extramural spread than CRM positive rectal cancers. Conclusion Retroperitoneal surgical resection margin involvement by caecal and ascending colon carcinoma is a marker of advanced tumour stage and associated with a high incidence of synchronous and metachronous distant metastasis. More aggressive surgery to obtain a clear margin or postoperative radiotherapy to the tumour bed is likely to benefit only a minority of patients.     

The morbidity and mortality of pediatric splenectomy: does prophylaxis make a difference?

PURPOSE: The aim of this study was to analyze the incidence of postsplenectomy sepsis morbidity and mortality after prophylaxis, in comparison with our previous 13-year study (1958 to 1970, inclusive). METHODS: All patients who had splenectomy at the Hospital for Sick Children, Toronto, between 1971 and 1995, inclusive (to give a minimum of 2 years for follow-up), were reviewed for infection and mortality. The criterion for classifying a patient as "infected" was the recovery of an invading encapsulated organism from the blood culture in a patient admitted to the hospital. RESULTS: Of the 264 patients studied, 10 had a postsplenectomy infection (3.8%); nine occurred in patients who underwent splenectomy between the ages of 0 and 5 years. Infection took place within 2 +/- 3 years (mean +/- SD) after splenectomy for the immunized patients and 11 +/- 5 days (mean +/- SD) for the nonimmunized children. A significant number of patients were admitted for an apparent respiratory infection, but no serum organisms were isolated. One died of overwhelming sepsis, but the responsible organism was not identified. CONCLUSION: Although there has not been a decrease in the number of splenectomies performed per year, the incidence of infection and mortality has decreased by 47% and 88%, respectively, with prophylaxis.     

Dimethyl sulfoxide: does it change the functional properties of the bladder wall?

PURPOSE: Dimethyl sulfoxide (DMSO) is used in a 50% solution to treat interstitial cystitis. Symptomatic relief occurs in about two-thirds of cases. The mechanism of action and effects of DMSO on bladder tissue function are poorly understood. Therefore, the effect of DMSO on bladder muscle compliance and contractility was evaluated. MATERIALS AND METHODS: Contractility and compliance were evaluated in rat bladder strips exposed to various concentrations of DMSO for 7 minutes, followed by 7 to 60-minute washout periods. The effect of DMSO at concentrations of 25%, 30%, 35%, 40% and 50% on electrical field stimulation induced contractions was assessed. Acetylcholine and high KCl (Sigma Chemical Co.) induced contractions were measured after exposure to 30% DMSO. Compliance was evaluated after exposure to 30% and 50% DMSO. RESULTS: Exposure to 40% DMSO completely abolished electrical field stimulation contractions, while 30% DMSO decreased the electrical field stimulation contraction to 40% +/- 6% of the initial force but there was almost complete recovery within 30 minutes. Contractile force was unaltered by 25% DMSO. Acetylcholine and KCl stimulation after exposure to 30% DMSO produced contractile forces of 78% +/- 6% and 39% +/- 6% of pre-DMSO control contractions, respectively. Compliance decreased by 2.4 and 4.6-fold following 30% and 50% DMSO exposure, respectively. CONCLUSIONS: DMSO completely and irreversibly abolishes contractions at a 40% concentration. Compliance is altered at even lower concentrations (30%). These findings bring into question the current practice of treating patients who have IC with 50% DMSO. Lower concentrations (25%) of DMSO may serve as a safe, effective analgesic and anti-inflammatory treatment for IC and other bladder pathologies.     

CMV and BKV ureteritis: which prognosis for the renal graft?

This report describes two cases of ureteral stricture in renal graft recipients related to cytomegalovirus (CMV) and human polyoma BK virus (BKV) ureteritis with the same onset characterized by acute graft failure with no clinical signs of systemic viral infections. The histological analysis did not show other causes of graft impairment (i.e. drug toxicity and acute rejection). Ultrasound scan (US) revealed absent or mild hydronephrosis. The diuretic-MAG3 renal scan showed a urinary flow obstruction. The viral genomes were isolated from urine, peripheral blood and graft or ureteral tissues samples. A percutaneous nephrostomy confirmed the stricture, but it restored urine flow only in the graft affected by CMV ureteritis, the association with a specific antiviral therapy probably produced a stable restoration of graft function. In BKV ureteritis,the graft prognosis was poor; graft loss could be due to the progress of BKV nephropathy. A correct differential diagnosis of the etiologic agent responsible for the ureteritis is mandatory, because treatment and outcome of the infection are different.     

Post-traumatic stress disorder symptoms following a head injury: does amnesia for the event influence the development of symptoms?

Background: There is controversy as to whether PTSD can develop following a brain injury with a loss of consciousness. However, no studies have specifically examined the influence of the memories that the individuals may or may not have on the development of symptoms. Aims: To consider how amnesia for the traumatic event effects the development and profile of traumatic stress symptoms. Method: Fifteen hundred case records from an Accident and Emergency Unit were screened to identify 371 individuals with traumatic brain injury who were sent questionnaires by post. The 53 subsequent valid responses yielded three groups: those with no memory (n = 14), untraumatic memories (n = 13) and traumatic memories (n = 26) of the index event. The IES-R was used as a screening measure followed by a structured interview (CAPS-DX) to determine caseness and provide details of symptom profile. Results: Groups with no memories or traumatic memories of the index event reported higher levels of psychological distress than the group with untraumatic memories. Ratings of PTSD symptoms were less severe in the no memory groups compared to those with traumatic memories. Conclusions: Psychological distress was associated with having traumatic or no memories of an index event. Amnesia for the event did not protect against PTSD; however, it does appear to protect against the severity and presence of specific intrusive symptoms.     

Hip preservation surgery—Can we change the natural history of osteoarthritis?

Structural abnormalities of the hip including developmental dysplasia (DDH) and femoroacetabular impingement (FAI) are a predominant cause of primary osteoarthritis. While affected patients may have significant pain and functional limitations, many may remain asymptomatic and will likely incur intra-articular damage over time. The objective of this review is to explore the natural history of DDH, FAI, and the current outcomes of hip preservation surgery including peri-acetabular osteotomy, hip arthroscopy, and surgical hip dislocation.