Pancreatic Islet Autotransplantation After Completion Pancreatectomy for Pancreatic Fistula After Hemipancreatoduodenectomy for Carcinoma

Objective

Pancreatic islet autotransplantation (IAT) has a potential to prevent brittle diabetes in patients after total pancreatectomy. Because of the fear of tumor spread, IAT has rarely been used in case of malignancy. We report our experience with patients who underwent hemipancreatoduodenectomy for carcinoma and later completion pancreatectomy for pancreatic fistula with islet autotransplantation at our institution.

Methods

From August 2007 to December 2012, 5 patients underwent IAT after completion pancreatectomy for pancreatic fistula after hemipancreatoduodenectomy for carcinoma. Islets were isolated from the pancreatic tail with the use of digestion with collagenase. Nonpurified islet suspension was infused into the portal vein during surgery.

Results

The median number of islets transplanted was 175,000 islet equivalents (range, 70,000–365,000). One patient died after surgery for reasons unrelated to IAT. Another 3 patients had stable diabetes with partial graft function (fasting C-peptide levels 0.23, 0.41, and 0.61 nmol/L and Hb_A1c 4.8%, 4.6%, and 6.9% at 24, 24 and 9 months after IAT, respectively). The 1st patient, with pancreatic head carcinoma, was alive 28 months after IAT with lymph node and liver recurrence since 18 months after IAT. The 2nd patient, with gall bladder and distal bile duct carcinoma, died 47 months after IAT with tumor recurrence. The 3rd patient, with ampullary carcinoma, died 12 months after IAT with local recurrence and solitary liver metastasis. The last patient had been off insulin 9 months after IAT without tumor recurrence (fasting C-peptide, 0.89 nmol/L; HbA1c, 4.2%).

Conclusions

Autotransplantation of pancreatic islets isolated from the residual pancreatic tissue in patients who previously underwent hemipancreatoduodenectomy for cancer may provide stable glucose control and thus improve quality of life. In this small series we did not observe early development of multiple liver metastases caused by islet suspension contamination with malignant cells. Oncologic outcome of the patients was not worse than what would be expected without IAT.     

Roux-en-Y Drainage of the Pancreatic Stump Decreases Pancreatic Fistula After Distal Pancreatic Resection

Clinically relevant fistula after distal pancreatic resection occurs in 5–30% of patients, prolonging recovery and considerably increasing in-hospital stay and costs. We tested whether routine drainage of the pancreatic stump into a Roux-en-Y limb after distal pancreatic resection decreased the incidence of fistula. From October 2001, data of all patients undergoing pancreatic distal resection were entered in a prospective database. From June 2003 after resection, the main pancreatic duct and the pancreatic stump were oversewn, and in addition, anastomosed into a jejunal Roux-en-Y limb by a single-layer suture (n = 23). A drain was placed near the anastomosis, and all patients received octreotide for 5–7 days postoperatively. The volume of the drained fluid was registered daily, and concentration of amylase was measured and recorded every other day. Patient demographics, hospital stay, pancreatic fistula incidence (≥30 ml amylase-rich fluid/day on/after postoperative day 10), perioperative morbidity, and follow-up after discharge were compared with our initial series of patients (treated October 2001–May 2003) who underwent oversewing only (n = 20). Indications, patient demographics, blood loss, and tolerance of an oral diet were similar. There were four (20%) pancreatic fistulas in the “oversewn” group and none in the anastomosis group (p < 0.05). Nonsurgical morbidity, in-hospital stay, and follow-up were comparable in both groups. Wagner and Gloor both contributed equally in this work.     

Prevention of Postoperative Pancreatic Fistula After Total Gastrectomy

BACKGROUND: Pancreatic fistula (PF) is still one of the serious complications after total gastrectomy (TG). The purpose of this study was to identify risk factors for PF after TG and to evaluate our attempts to prevent PF. METHODS: From August 1992 to July 2006, 740 consecutive patients with gastric neoplasm underwent TG at the National Cancer Center Hospital East. Univariate and multivariate analyses of potential risk factors for the development of PF and the effectiveness of operative procedures to prevent PF were performed. RESULTS: Postoperative PF was identified in 130 patients (18%). On multivariate analysis, body mass index (P < 0.001) and the operative procedure (TG with pancreaticosplenectomy) (P = 0.001) were independent risk factors. In TG with splenectomy (pancreas-preserving method), total preservation of the splenic artery was significantly correlated with a lower incidence of PF (P < 0.001). In TG with pancreaticosplenectomy, the use of a linear stapling device was an effective surgical technique for closure of the cut end of the pancreas, but there was no significant difference from conventional methods. Recently, the incidence decreased significantly for TG overall and TG with splenectomy. CONCLUSIONS: PF after TG is more likely to occur in obese patients undergoing TG with pancreaticosplenectomy. When TG with splenectomy (pancreas-preserving method) is performed, the splenic artery should be totally preserved. If TG with pancreaticosplenectomy is performed, the use of a linear stapling device for closure of the cut end of the pancreas should be suggested. These improvements in surgical techniques are useful to prevent PF.     

Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection

Background  

The anatomical status of the pancreatic remnant after a pancreatic head resection varies greatly among patients. The aim of the present study was to improve management of the pancreatic remnant for reducing pancreatic fistula after pancreatic head resection.     

Reduced Postoperative Pancreatic Fistula Rate After Pancreatogastrostomy Versus Pancreaticojejunostomy

Introduction  Metaanalysis of retrospective studies employing various definitions of pancreatic fistulas demonstrated a reduced postoperative pancreatic fistula rate after pancreatogastrostomy versus pancreaticojejunostomy. Prospective trials failed to do so, which causes an ongoing debate on the superiority of one or the other procedure. The aim of this study was to compare the two types of anastomosis at our institution with regard to postoperative pancreatic fistula and other complications. Materials and Methods  From 2001 to 2007, 114 pancreatogastrostomies and 115 pancreaticojejunostomies were performed. For retrospective analysis, the ISGPS definitions were employed. Primary endpoint was the occurrence of postoperative pancreatic fistula grade B or C. Secondary endpoints were postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal fluid collection, reoperation, and mortality. Operative time, intensive care unit stay, and overall hospital stay were also compared. Results  With pancreatogastrostomy, there were significantly less postoperative pancreatic fistulae grade B and C (pancreatogastrostomy (PG) versus pancreaticojejunostomy (PJ), 11.4% versus 22.6%, p = 0.03), more intraluminal hemorrhage (PG versus PJ, 10.5% versus 0%, p < 0.001) and more delayed gastric emptying grade B and C (PG versus PJ, 18.3% versus 7.9%, p = 0.03). Operative time was shorter (PG versus PJ, median 420 versus 450 min, p < 0.01), and intensive care unit stay was longer (PG versus PJ, median 4 days versus 5 days, p < 0.01), with a tendency toward reduced overall hospital stay (PG versus PJ, median 17 versus 19 days, p = 0.08). Conclusion  Surgeons should be aware of a higher rate of delayed gastric emptying and perform meticulous hemostasis to prevent intraluminal bleeding with pancreatogastrostomy. Pancreatogastrostomy is superior to pancreaticojejunostomy in terms of relevant postoperative pancreatic fistula.     

Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy

Background

Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).

Methods

Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance.

Results

POPF was identified in 17.3% of patients (n?=?18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p?=?0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03–1.55, p?=?0.03).

Conclusion

High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.

     

High Expression of Delta-Like Ligand 4 Predicts Poor Prognosis After Curative Resection for Pancreatic Cancer

Background

Delta-like ligand 4 (DLL4)-Notch signaling plays a key role in tumor angiogenesis, but its prognostic value in patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Our aim was to determine whether high DLL4 expression is correlated with poor prognosis after curative resection for PDAC.

Methods

Surgical specimens obtained from 89 patients with PDAC were immunohistochemically assessed for DLL4 and vascular endothelial growth factor receptor 2 (VEGFR-2) expression. Prognostic significance of DLL4 expression was evaluated by Kaplan–Meier method and Cox regression. The correlations of DLL4 expression with VEGFR-2 expression, tumor stage, and lymph node metastasis were examined by chi-square test and multivariate logistic regression.

Results

There were 38 (42.7%) and 51 patients who showed high and low DLL4 expression, respectively. Survival curves showed that patients with low DLL4 expression had a significantly better survival than those with high DLL4 expression (P < .001). Multivariate survival analysis demonstrated that high DLL4 expression was independently associated with both reduced overall survival (hazard ratio [HR] 2.24; 95% confidence interval [95% CI] 1.14–4.38) and reduced progression-free survival (HR 2.37; 95% CI 1.22–4.60). Multivariate logistic regression analyses showed that high DLL4 expression was independently associated with both advanced tumor stage (odds ratio [OR] 6.84; 95% CI 2.42–9.36) and lymph node metastasis (OR 3.27; 95% CI 1.04–10.34). We also found a positive correlation between DLL4 and VEGFR-2 expression (P < .001).

Conclusions

High DLL4 expression is significantly associated with poor prognosis for surgically resected PDAC, advanced tumor stage, and lymph node metastasis. Application of adjuvant therapy targeting DLL4-Notch signaling may improve prognosis.

     

High Expression of Delta-Like Ligand 4 Predicts Poor Prognosis After Curative Resection for Pancreatic Cancer

Background

Delta-like ligand 4 (DLL4)-Notch signaling plays a key role in tumor angiogenesis, but its prognostic value in patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Our aim was to determine whether high DLL4 expression is correlated with poor prognosis after curative resection for PDAC.

Methods

Surgical specimens obtained from 89 patients with PDAC were immunohistochemically assessed for DLL4 and vascular endothelial growth factor receptor 2 (VEGFR-2) expression. Prognostic significance of DLL4 expression was evaluated by Kaplan–Meier method and Cox regression. The correlations of DLL4 expression with VEGFR-2 expression, tumor stage, and lymph node metastasis were examined by chi-square test and multivariate logistic regression.

Results

There were 38 (42.7%) and 51 patients who showed high and low DLL4 expression, respectively. Survival curves showed that patients with low DLL4 expression had a significantly better survival than those with high DLL4 expression (P < .001). Multivariate survival analysis demonstrated that high DLL4 expression was independently associated with both reduced overall survival (hazard ratio [HR] 2.24; 95% confidence interval [95% CI] 1.14–4.38) and reduced progression-free survival (HR 2.37; 95% CI 1.22–4.60). Multivariate logistic regression analyses showed that high DLL4 expression was independently associated with both advanced tumor stage (odds ratio [OR] 6.84; 95% CI 2.42–9.36) and lymph node metastasis (OR 3.27; 95% CI 1.04–10.34). We also found a positive correlation between DLL4 and VEGFR-2 expression (P < .001).

Conclusions

High DLL4 expression is significantly associated with poor prognosis for surgically resected PDAC, advanced tumor stage, and lymph node metastasis. Application of adjuvant therapy targeting DLL4-Notch signaling may improve prognosis.

     

Association Between the Incidence of Pancreatic Fistula After Pancreaticoduodenectomy and the Degree of Pancreatic Fibrosis

Objective

The objective of this study is to investigate the association between the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) and the degree of pancreatic fibrosis.

Method

Between January 2013 and December 2016, the analysis of the clinical data of 529 cases of pancreaticoduodenectomy patients of our hospital was performed in a retrospective fashion. The univariate analysis and multivariate analysis were done using the Pearson chi-squared test and binary logistic regression analysis model; correlations were analyzed by Spearman rank correlation analysis. The value of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy was evaluated by the area under the receiver operating characteristic (ROC) curve.

Results

The total incidence of pancreatic fistula after pancreaticoduodenectomy was 28.5% (151/529). Univariate analysis and multivariate analysis showed that BMI?≥?25 kg/m², pancreatic duct size ≤?3 mm, pancreatic CT value<?30, the soft texture of the pancreas (judged during the operation), and the percent of fibrosis of pancreatic lobule ≤?25% are prognostic factors of pancreatic fistula after pancreaticoduodenectomy (P?<?0.05); the pancreatic CT value and the percent of fibrosis of pancreatic lobule in pancreatic fistula group were both lower than those in non-pancreatic fistula group (P?<?0.05). Results indicated that there is a negative correlation between the severity of pancreatic fistula and the pancreatic CT value or the percent of fibrosis of pancreatic lobule (r?=???0.297, ??0.342, respectively). The areas under the ROC curve of the percent of fibrosis of pancreatic lobule and the pancreatic CT value were 0.756 and 0.728, respectively.

Conclusion

The degree of pancreatic fibrosis is a prognostic factor which can influence the pancreatic texture and the incidence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic CT value can be used as a quantitative index of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy.

     

Schematic Pancreatic Configuration: A Risk Assessment for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Introduction

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

Methods

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4 %), grade B in 84 (26.4 %), and grade C in 6 (1.9 %).

Conclusions

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.     

Different Recurrence Pattern After Neoadjuvant Chemoradiotherapy Compared to Surgery Alone in Esophageal Cancer Patients

Purpose

To evaluate the rate and pattern of recurrences after neoadjuvant chemoradiotherapy (CRT) in esophageal cancer patients.

Methods

We described survival and differences in recurrences from a single center between neoadjuvant CRT (carboplatin/paclitaxel and 41.4 Gy) and surgery alone for the period 2000–2011. To reduce bias, we performed a propensity score matched analysis.

Results

A total of 204 patients were analyzed, 75 treated with neoadjuvant CRT and 129 with surgery alone. The pathologic response to neoadjuvant CRT was 69 % with a complete response rate of 25 %. After matching, baseline characteristics between the groups (both n = 75) were equally distributed. The 3- and 5-year disease-free survival was 53 and 42 % in the neoadjuvant CRT group compared with 24 and 18 % in the surgery-alone group (P = 0.011). After 3 and 5 years’ CRT, patients had an estimated locoregional recurrence-free survival of 83 and 73 % compared with 52 and 49 % in the surgery-alone group (P = 0.015). The distant recurrence-free survival was comparable in both groups. Locoregional recurrences were located less in the paraesophageal lymph nodes in the CRT group than in the surgery-alone group, 9 versus 21 %, respectively (P = 0.041). With respect to differences in distant recurrences, we observed more skeletal recurrences in the surgery-alone group compared to CRT, 12 versus 1 % (P = 0.009).

Conclusions

The neoadjuvant CRT regimen we used offers a significant improvement in outcome, with a different recurrence pattern compared with surgery alone. This effect is probably due to both the pathologic complete response and eradication of micrometastases in CRT group.     

Pancreatic Fistula Rates After 462 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates

Introduction  Pancreatic fistula is a major source of morbidity after distal pancreatectomy (DP). We reviewed 462 consecutive patients undergoing DP to determine if the method of stump closure impacted fistula rates. Methods  A retrospective review of clinicopatologic variables of patients who underwent DP between February 1994 and February 2008 was performed. The International Study Group classification for pancreatic fistula was utilized (Bassi et al., Surgery, 138(1):8–13, 2005). Results  The overall pancreatic fistula rate was 29% (133/462). DP with splenectomy was performed in 321 (69%) patients. Additional organs were resected in 116 (25%) patients. The pancreatic stump was closed with a fish-mouth suture closure in 227, of whom 67 (30%) developed a fistula. Pancreatic duct ligation did not decrease the fistula rate (29% vs. 30%). A free falciform patch was used in 108 patients, with a fistula rate of 28% (30/108). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (15/45). There is no significant difference in the rate of fistula formation between the different stump closures (p = 0.73). On multivariate analysis, BMI > 30 kg/m², male gender, and an additional procedure were significant predictors of pancreatic fistula. Conclusions  The pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after DP. Reduction of pancreatic fistulas after DP remains an unsolved challenge. Presented at the DDW in San Diego, CA, USA, May 21, 2008.     

Recurrence Location After Resection of Colorectal Liver Metastases Influences Prognosis

Aim

To assess the impact of first recurrence location on survival following surgery of colorectal liver metastases.

Methods

A total of 265 consecutive patients with colorectal liver metastases undergoing liver surgery (2000–2011) were categorized according to first site of tumor recurrence. Time to recurrence (TTR) and overall survival (OS) were determined. Uni- and multivariate analysis were performed to identify factors associated with TTR and OS.

Results

Median TTR was 1.16 years following liver resection, and 0.56 years following radiofrequency ablation (RFA). Intrahepatic recurrence following liver resection resulted in a significantly shorter median TTR compared to extrahepatic recurrence. Intrapulmonary recurrence was associated with superior survival compared to other recurrence locations. Such patterns were not observed in the RFA-treated group. Multivariate analysis identified the type of surgical treatment and extra-hepatic first-site recurrence (other than lung) as independent predictors for OS. Pre-operative chemotherapy and simultaneous intrahepatic and extrahepatic recurrence were independent predictors for both TTR and OS.

Conclusions

Patients with intrahepatic recurrence following liver resection have a significantly shorter TTR and OS when compared to patients developing extrahepatic recurrence. Pulmonary recurrence following resection is associated with longer survival. Simultaneous intra- and extrahepatic recurrence is an independent prognostic factor for TTR and OS.     

Redefining Mortality After Pancreatic Cancer Resection

Introduction

Distinct outcome measures such as in-hospital and 30-day mortality have been used to evaluate pancreatectomy results. We posited that these measures could be compared using national data, providing more precision for evaluating published outcomes after pancreatectomy.

Methods

Patients undergoing resection for pancreatic cancer were identified from the linked SEER-Medicare databases (1991–2002). Mortality was analyzed and trend tests were utilized to evaluate risk of death within ≤60 days of resection and from 60 days to 2 years post-resection. Univariate analysis assessed patient characteristics such as race, gender, marital status, socioeconomic status, hospital teaching status, and complications.

Results

One thousand eight hundred forty-seven resected patients were identified: 7.7% (n?=?142) died within the first 30 days, 83.6% of whom died during the same hospitalization. Postoperative in-hospital mortality was 8.1% (n?=?150), 79% of which was within 30 days, greater than 90% of which was within 60 days. Risk of death decreased significantly over the first 60 days (P?<?0.0001). After 60 days, the risk did not decrease through 2 years (P?=?0.8533). Univariate analysis showed no difference between the two groups in terms of race, gender, marital status, and socioeconomic status, but patients dying within 60 days were more likely to have experienced a complication (41.1% vs. 17.0%, P?<?0.0001).

Conclusions

In-hospital and 30-day mortality after resection for cancer are similar nationally; thus, comparing mortality utilizing these measures is acceptable. After a 60-day post-resection window of increased mortality, mortality risk then continues at a constant rate over 2 years, suggesting that mortality after pancreatectomy is not limited to early (“complication”) and late (“cancer”) phases. Determining ways to decrease perioperative mortality in the 60-day interval will be critical to improving overall survival.     

Prognosis After Reoperation for Local Recurrence of Papillary Thyroid Carcinoma

Purpose To investigate the factors associated with a favorable prognosis after reoperation for local recurrent papillary thyroid carcinoma (PTC), we reviewed 45 patients who underwent surgery for first local recurrence of PTC.Methods We divided the patients into two groups. Group A (n = 28) had no second recurrence, and group B (n = 17) had second local recurrence after surgery for recurrence.Results The mean follow-up period after reoperation was 56.9 months. The mean age at the time of reoperation in group A was significantly lower than that in group B, at 48.1 years versus 62.3 years, respectively (P = 0.0007). The mean age at the time of the initial operation in group A was also significantly lower than that in group B, at 40.1 years versus 55.1 years, respectively (P = 0.0006). Patients with recurrent tumors only outside the area dissected at the initial operation (n = 27) had a better outcome than those with recurrence within the dissected area (n = 18; P = 0.0127). Patients who underwent systematic partial or modified neck dissection (n = 36) had a better outcome than those who underwent only simple local resection (n = 9; P = 0.0169).Conclusion For local recurrent PTC, systematic neck dissection is recommended over local resection of recurrent tumors.     

Identification of Subsets of Patients with Favorable Prognosis After Recurrence in Completely Resected Non-Small Cell Lung Cancer

Background

This retrospective study aimed to determine prognostic factors associated with postrecurrence survival of completely resected non-small cell cancer patients with postoperative recurrence.

Methods

Characteristics, treatment modality, and postrecurrence survival of 234 patients (157 males and 77 females, mean age at recurrence: 68.7 years, 152 adenocarcinomas and 82 non-adenocarcinomas), who underwent complete resection for non-small cell lung cancer between 2003 and 2009 at our hospital and experienced recurrence, were analyzed for prognostic factors. Cox proportional hazard model was applied for multivariate analysis.

Results

Among 234 patients, the median survival time after the diagnosis of recurrence was 21 months, and the 5-year postrecurrence survival rate was 19.9 %. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (hazard ratio [HR]: ECOG PS-0/PS-1/PS-2 = 1/3.313/7.622), time to recurrence after surgery (HR: >2 years/1–2 years/<1 year = 1/1.881/2.185), and number of initial recurrent organs (HR: 1 organ/2 organs/3 or more organs = 1/1.896/2.818) were independent prognostic factors. Patients who received resection or stereotactic irradiation for limited number of brain metastases or solitary extracranial metastasis, and those who received mediastinal radiation or chemoradiation for recurrence at regional lymph nodes and/or resected stump had better survival (median survival time after recurrence: 34, 64, and 25 months, respectively).

Conclusions

Poor ECOG PS, shorter time from initial surgery to recurrence, and increasing number of initial recurrent regions are associated with poor prognosis after recurrence. When the number of recurrent lesions is limited, intensive local treatment with curative intent should be applied for achieving long-term postrecurrence survival.     

Prognostic Factors After Resection of Pancreatic Cancer

Objectives  The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient’s general condition. Methods  Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses. Results  The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration >100 U/ml (HR = 1.84, p = 0.0074), a tumor size >3 cm (HR = 1.74, p = 0.0235), venous involvement (HR = 2.39, p = 0.0006), a transfusion requirement of ≥1000 ml (HR = 2.23, p = 0.0006), and a serum albumin concentration on 1 postoperative month (1POM) < 3 g/dl (HR = 2.40, p = 0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p = 0.0041), extended nerve plexus resection around the superior mesenteric artery (p = 0.0456), and a longer postoperative hospital stay (p = 0.0063). Conclusion  To improve long-term survival, preserving the patient’s general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.     

Postoperative Complications Influence Prognosis and Recurrence Patterns in Periampullary Cancer

Background

The present study was performed to elucidate the influence of postoperative complications on the prognosis and recurrence patterns of periampullary cancer after pancreaticoduodenectomy (PD).

Methods

Clinical data were reviewed from 200 consecutive patients who had periampullary cancer and underwent PD between October 2003 and July 2010, and survival outcomes and recurrence patterns were analyzed. Postoperative complications were classified according to a modification of Clavien’s classification.

Results

Overall, 86 major complications of grade II or higher occurred in 71 patients. The patients were classified into two groups according to the presence of postoperative complications of grade II or higher: group Cx?, absence of complications (n = 129); and group Cx+, presence of complications (n = 71). There were no differences in gender, mean age, tumor node metastasis stage, biliary drainage, type of resection, and radicality between the two groups (P > 0.05). The 3-year overall and disease-free survival rates of the group Cx+ patients (31.0 and 22.3 %, respectively) were significantly lower than those of the group Cx? patients (49.0 and 40.0 %; P = 0.003 and 0.002, respectively). The multivariate analysis showed that postoperative complications (P = 0.001; RR = 1.887; 95 % confidence interval [CI] 1.278–2.785), a T stage of T3 or T4 (P = 0.001; RR = 2.503; 95 % CI 1.441–4.346), positive node metastasis (P = 0.001; RR = 2.093; 95 % CI, 1.378–3.179), R1 or R2 resection (P = 0.023; RR = 1.863; 95 % CI 1.090–3.187), and angiolymphatic invasion (P = 0.013; RR = 1.676; 95 % CI 1.117–2.513) were independent prognostic factors for disease-free survival. Regarding recurrence patterns, group Cx+ patients exhibited more distant recurrences than did group Cx? patients (P = 0.025).

Conclusions

Postoperative complications affect prognosis and recurrence patterns in patients with periampullary cancer after PD.