1
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Wismans LV, Hendriks TE, Suurmeijer JA, Nuyttens JJ, Bruynzeel AM, Intven MP, van Driel LM, Haen R, de Wilde RF, Groot Koerkamp B, Busch OR, Stoker J, Verheij J, Farina A, de Boer OJ, Doukas M, de Hingh IH, Lips DJ, van der Harst E, van Tienhoven G, van Eijck CH, Besselink MG. Preoperative stereotactic radiotherapy to prevent pancreatic fistula in high-risk patients undergoing pancreatoduodenectomy (FIBROPANC): prospective multicentre phase II single-arm trial. Br J Surg 2025; 112:znae327. [PMID: 39891429 PMCID: PMC11785728 DOI: 10.1093/bjs/znae327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2024] [Revised: 12/18/2024] [Accepted: 12/18/2024] [Indexed: 02/03/2025]
Abstract
BACKGROUND Postoperative pancreatic fistula is the main driver of morbidity and mortality after pancreatoduodenectomy. In high-risk patients, the rate of postoperative pancreatic fistula approaches 50%, whereas it is below 5% in patients with pancreatic cancer who receive neoadjuvant chemoradiotherapy. The aim of this study was to evaluate the safety, feasibility, and efficacy of preoperative stereotactic body radiotherapy on the pancreatic neck transection margin in high-risk patients undergoing pancreatoduodenectomy to prevent postoperative pancreatic fistula. METHODS In this prospective multicentre open-label single-arm trial (progressing from a safety run-in phase to a phase II design), patients undergoing pancreatoduodenectomy for neoplasms other than pancreatic ductal adenocarcinoma received a single preoperative stereotactic body radiotherapy dose of 12 Gy. Primary endpoints included safety (less than or equal to 15% grade 3-5 toxicity), feasibility (a significant change in pancreatic texture measured using a durometer), and efficacy (a 15% reduction in the grade B/C postoperative pancreatic fistula rate compared with patients from the Dutch Pancreatic Cancer Audit who were eligible but not included in this study). Secondary endpoints assessed tissue fibrosis (collagen density). RESULTS Overall, 38 patients were included, of whom 33 (87%) completed the study protocol and were included in the per-protocol analysis. The safety cut-off was met, with 3% grade 3-5 toxicity. Pancreatic tissue treated with stereotactic body radiotherapy showed increased firmness using a durometer (median of 47 (interquartile range 36-57) versus 37 (interquartile range 30-41) Shore OO units; P < 0.001) and a higher collagen density (median of 6.1% (interquartile range 4.4%-9.5%) versus 4.6% (interquartile range 2.5%-7.4%); P = 0.003). The grade B/C postoperative pancreatic fistula rate with stereotactic body radiotherapy was 57.6% (95% c.i. 41% to 74%), compared with 34% (95% c.i. 27% to 42%) in audit controls (P = 0.011). CONCLUSION Preoperative stereotactic body radiotherapy is safe in high-risk patients undergoing pancreatoduodenectomy and increases parenchymal firmness and fibrosis, but fails to show evidence of efficacy.
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Affiliation(s)
- Leonoor V Wismans
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tessa E Hendriks
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anna M Bruynzeel
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn P Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lydi M van Driel
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roel Haen
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roeland F de Wilde
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jaap Stoker
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Onno J de Boer
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Michail Doukas
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geertjan van Tienhoven
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Erasmus Medical Center Cancer Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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2
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Kriener K, Sinclair K, Robison G, Lala R, Finley H, Richardson WJ, Midwinter MJ. Investigating the Reliability of Shore Hardness in the Design of Procedural Task Trainers. Bioengineering (Basel) 2025; 12:41. [PMID: 39851315 PMCID: PMC11762807 DOI: 10.3390/bioengineering12010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Revised: 12/17/2024] [Accepted: 12/20/2024] [Indexed: 01/26/2025] Open
Abstract
The haptic fidelity of biomimetic materials used in the design of procedural task trainers is of growing interest to the medical community. Shore hardness has been proposed as a method for assessing tissue biomechanics and replicating the results as a way to increase the fidelity of biomimetics to tissues. However, there is limited research on the reliability of human tissue measurements using Shore scales. Using human tissues (internal carotid artery [ICA], internal jugular vein [IJV], vagus nerve [VN], sternocleidomastoid muscle [SCM], and overlying skin [skin]), this study evaluates (1) the inter-rater reliability of Shore hardness measurements, (2) examines the relationship between tissue thickness and hardness, and (3) investigates the impact of a measurement method (freehand vs. durometer stand). Preserved tissues, specifically a liver and components of the anterior triangle of the neck, were extracted from cadavers and measured by three independent raters using digital Shore durometers. Testing revealed that although Shore A demonstrated better inter-rater reliability compared to Shore OO, both scales exhibited poor-to-moderate reliability. ICC values for Shore A ranged from 0.21 to 0.80 and were statistically significant (p < 0.05) for all tissue types except the SCM. In contrast, Shore OO demonstrated poorer reliability, with ICC values ranging from 0.00 to 0.41. The ICC values were only significant for the ICA, IJV, and VN (p < 0.05). An inverse correlation between tissue thickness and hardness on the Shore A scale was found for all tissues and was significant (p < 0.05) for ICA, VN, and skin. There were mixed results for the correlation between tissue thickness and hardness on the Shore OO scale (-0.06-0.92), and only IJV had a statistically significant correlation (p < 0.05). Finally, the median hardness values on the Shore OO scale were significantly greater when measured using a durometer stand vs. freehand (Z = 4.78, p < 0.05). In summary, when using appropriate standards and addressing the challenges of tissue thickness and variability in freehand measures, Shore hardness has the potential to be used by clinicians in the clinical setting and in the selection of biomimetic materials in the design of task trainers.
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Affiliation(s)
- Kyleigh Kriener
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
- Ochsner Clinical School, 1401 Jefferson Hwy, Jefferson, LA 70121, USA
| | - Kate Sinclair
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
| | - Grant Robison
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
- Ochsner Clinical School, 1401 Jefferson Hwy, Jefferson, LA 70121, USA
| | - Raushan Lala
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
| | - Hayley Finley
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
| | - William Jase Richardson
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
| | - Mark J. Midwinter
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia; (K.S.); (W.J.R.)
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Suurmeijer JA, Wismans LV, Hendriks TE, Bruynzeel AM, Nuyttens JJ, Intven MP, van Driel LM, Groot Koerkamp B, Busch OR, Stoker JJ, Verheij J, Farina A, Doukas M, de Hingh IH, Lips DJ, van der Harst E, van Tienhoven G, Besselink MG, van Eijck CH, for the Dutch Pancreatic Cancer Group. Feasibility, safety and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the risk of pancreatic fistula after high-risk pancreatoduodenectomy (FIBROPANC): protocol for a multicentre, single-arm trial. BMJ Open 2024; 14:e087193. [PMID: 39317507 PMCID: PMC11423754 DOI: 10.1136/bmjopen-2024-087193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 09/06/2024] [Indexed: 09/26/2024] Open
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) occurs in 25% of patients undergoing a high-risk pancreatoduodenectomy (PD) and is a driving cause of major morbidity, mortality, prolonged hospital stay and increased costs after PD. There is a need for perioperative methods to decrease these risks. In recent studies, preoperative chemoradiotherapy in patients with pancreatic ductal adenocarcinoma (PDAC) reduced the rate of POPF seemingly due to radiation-induced pancreatic fibrosis. However, patients with a high risk of POPF mostly have a non-pancreatic periampullary tumour and do not receive radiotherapy. Prospective studies using radiotherapy specifically to reduce the risk of POPF have not been performed. We aim to assess the safety, feasibility and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the rate of POPF. METHODS AND ANALYSIS In this multicentre, single-arm, phase II trial, we aim to assess the feasibility and safety of a single fraction of preoperative stereotactic radiotherapy (12 Gy) to a 4 cm area around the future pancreatic neck transection margin in patients at high risk of developing POPF after PD aimed to reduce the risk of grade B/C POPF. Adult patients scheduled for PD for malignant and premalignant periampullary tumours, excluding PDAC, with a pancreatic duct diameter ≤3 mm will be included in centres participating in the Dutch Pancreatic Cancer Group. The primary outcome is the safety and feasibility of single-dose preoperative stereotactic radiotherapy before PD. The most relevant secondary outcomes are grade B/C POPF and the difference in the extent of fibrosis between the radiated and non-radiated (uncinate margin) pancreas. Evaluation of endpoints will be performed after inclusion of 33 eligible patients. ETHICS AND DISSEMINATION Ethical approval was obtained by the Amsterdam UMC's accredited Medical Research Ethics Committee (METC). All included patients are required to have provided written informed consent. The results of this trial will be used to determine the need for a randomised controlled phase III trial and submitted to a high-impact peer-reviewed medical journal regardless of the study outcome. TRIAL REGISTRATION NUMBER NL72913 (Central Committee on Research involving Human Subjects Registry) and NCT05641233 (ClinicalTrials).
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Affiliation(s)
- J. Annelie Suurmeijer
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Leonoor V. Wismans
- Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Tessa E. Hendriks
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Anna M. Bruynzeel
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Radiation Oncology, Amsterdam UMC, location VU University, Amsterdam, The Netherlands
| | - Joost J. Nuyttens
- Radiation Oncology, Erasmus MC, University Medical Center, Rotterdm, the Netherlands
| | - Martijn P.W. Intven
- Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Bas Groot Koerkamp
- Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jaap J. Stoker
- Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Michail Doukas
- Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ignace H.J. de Hingh
- Surgery, Catharina Hospital, Catharina Cancer Institute, Eindhoven, the Netherlands
| | - Daan J. Lips
- Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Radiation Oncology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G. Besselink
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Casper H.J. van Eijck
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Radiation Oncology, Amsterdam UMC, location VU University, Amsterdam, The Netherlands
- Radiation Oncology, Erasmus MC, University Medical Center, Rotterdm, the Netherlands
- Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Pathology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Surgery, Catharina Hospital, Catharina Cancer Institute, Eindhoven, the Netherlands
- Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Surgery, Maasstad Hospital, Rotterdam, The Netherlands
- Radiation Oncology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
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4
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Brown J, Bello F. Hardness changing tactile displays for simulating the feel of organic tissues. Front Robot AI 2024; 11:1404543. [PMID: 39228689 PMCID: PMC11368671 DOI: 10.3389/frobt.2024.1404543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/26/2024] [Indexed: 09/05/2024] Open
Abstract
Physical interaction with patients, for example conducted as part of a diagnostic examination or surgical procedure, provides clinicians with a wealth of information about their condition. Simulating this interaction is of great interest to researchers in both haptics and medical education, and the development of softness changing tactile interfaces is important in recreating the feel of different soft tissues. This paper presents designs for a variety of novel electromechanical and electromagnetic mechanisms for controlling particle jamming-based, hardness changing tactile displays, intended to allow medical trainees to experience these physical interactions in a range of simulation settings such as clinical skills teaching laboratories. Each design is then subjected to a battery of mechanical tests to evaluate its effectiveness compared to the state of the art, as well as their suitability for simulating the physical hardness of different types of soft tissues, previously characterised in established literature. These results demonstrate that all of the technologies presented are able to exhibit a measurable hardness change, with Shore hardness values between 3A and 57A achieved by the most effective constriction-based device. The electromechanical devices based on constriction and compression, and the state-of-the-art pneumatic device, were able to achieve hardness changes within a range that is useful for replicating the softness of organic tissue. The electromechanical and electromagnetic devices were also found to effect their full range of hardness change in less than a second, compared to several seconds for the state-of-the-art. These results show that the performance of softness changing tactile displays can be improved with the electromechanical actuation techniques proposed in this paper, and that such displays are able to replicate the physical characteristics of soft tissues and may therefore be of benefit in medical training and simulation scenarios.
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Affiliation(s)
- Joshua Brown
- Simulation and Modelling in Medicine and Surgery (SiMMS) Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Joshi K, Espino DM, Shepherd DE, Mahmoodi N, Roberts KJ, Chatzizacharias N, Marudanayagam R, Sutcliffe RP. Pancreatic anastomosis training models: Current status and future directions. Pancreatology 2024; 24:624-629. [PMID: 38580492 DOI: 10.1016/j.pan.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/23/2024] [Accepted: 03/27/2024] [Indexed: 04/07/2024]
Abstract
Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback.
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Affiliation(s)
- Kunal Joshi
- Department of HPB surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
| | - Daniel M Espino
- Department of Mechanical Engineering, University of Birmingham, UK
| | | | - Nasim Mahmoodi
- Department of Mechanical Engineering, University of Birmingham, UK
| | - Keith J Roberts
- Department of HPB surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
| | - Nikolaos Chatzizacharias
- Department of HPB surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
| | - Ravi Marudanayagam
- Department of HPB surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
| | - Robert P Sutcliffe
- Department of HPB surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK.
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Laws AC, Traverson M, Wood M, Harrysson OLA. Novel 3D Custom-Made Silicone Tumor Model as a Support for Teaching Surgical Oncology Principles. JOURNAL OF VETERINARY MEDICAL EDUCATION 2024; 51:394-404. [PMID: 37276546 DOI: 10.3138/jvme-2022-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Alternative laboratory teaching methods are becoming increasingly desirable and effective in medical education environments. While ethical concerns associated with the use of live animals in terminal surgery laboratories have been reduced with cadaveric models, availability, and lack of pathology can limit their ability to adequately convey surgical principles and replicate clinical training. We have developed a three-dimensional (3D) custom-made silicone soft tissue tumor model using 3D-printed molds derived from canine soft tissue sarcoma computed tomography images. This novel teaching model allows users to apply surgical oncology principles and perform basic technical tasks such as incisional biopsy, margin demarcation, marginal and wide surgical excision, and inking of surgical margins. A large cohort of students in addition to a small number of professional veterinarians at different levels of specialty training followed the laboratory guidelines and evaluated the simulated tumor model based on a qualitative survey. All participants were able to successfully complete the practical training. The model also allowed the students to identify and correct technical errors associated with biopsy sampling and margin dissection, and to understand the clinical impacts related to those errors. Face and content validity of the model were assessed using Likert-style questionnaires with overall average instructors' scores of 3.8/5 and 4.6/5, respectively. Content validity assessment of the model by the students approximated instructors' evaluation with an overall average score of 4.4/5. This model development emphasizes the efficacy of alternative non-cadaveric laboratory teaching tools and could become a valuable aid in the veterinary curricula.
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Affiliation(s)
- Abigail Cox Laws
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606 USA
| | - Marine Traverson
- Fellow of Surgical Oncology, Department of Clinical Sciences, College of Veterinary Medicine; Center for Additive Manufacturing and Logistics, College of Engineering, North Carolina State University, Raleigh, NC 27606 USA
| | - Maddie Wood
- Center for Additive Manufacturing and Logistics, Fitts Department of Industrial and Systems Engineering, College of Engineering, North Carolina State University, Raleigh, NC 27606 USA
| | - Ola L A Harrysson
- Center for Additive Manufacturing and Logistics, Fitts Department of Industrial and Systems Engineering, College of Engineering; Department of Biomedical Engineering, College of Engineering; Department of Material Science and Engineering, College of Engineering, North Carolina State University, Raleigh, NC 27606 USA
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7
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Wismans LV, Suurmeijer JA, van Dongen JC, Bonsing BA, Van Santvoort HC, Wilmink JW, van Tienhoven G, de Hingh IH, Lips DJ, van der Harst E, de Meijer VE, Patijn GA, Bosscha K, Stommel MW, Festen S, den Dulk M, Nuyttens JJ, Intven MPW, de Vos-Geelen J, Molenaar IQ, Busch OR, Koerkamp BG, Besselink MG, van Eijck CHJ. Preoperative chemoradiotherapy but not chemotherapy is associated with reduced risk of postoperative pancreatic fistula after pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a nationwide analysis. Surgery 2024; 175:1580-1586. [PMID: 38448277 DOI: 10.1016/j.surg.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/01/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula remains the leading cause of significant morbidity after pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Preoperative chemoradiotherapy has been described to reduce the risk of postoperative pancreatic fistula, but randomized trials on neoadjuvant treatment in pancreatic ductal adenocarcinoma focus increasingly on preoperative chemotherapy rather than preoperative chemoradiotherapy. This study aimed to investigate the impact of preoperative chemotherapy and preoperative chemoradiotherapy on postoperative pancreatic fistula and other pancreatic-specific surgery related complications on a nationwide level. METHODS All patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included in the mandatory nationwide prospective Dutch Pancreatic Cancer Audit (2014-2020). Baseline and treatment characteristics were compared between immediate surgery, preoperative chemotherapy, and preoperative chemoradiotherapy. The relationship between preoperative chemotherapy, chemoradiotherapy, and clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery grade B/C) was investigated using multivariable logistic regression analyses. RESULTS Overall, 2,019 patients after pancreatoduodenectomy for pancreatic ductal adenocarcinoma were included, of whom 1,678 underwent immediate surgery (83.1%), 192 (9.5%) received preoperative chemotherapy, and 149 (7.4%) received preoperative chemoradiotherapy. Postoperative pancreatic fistula occurred in 8.3% of patients after immediate surgery, 4.2% after preoperative chemotherapy, and 2.0% after preoperative chemoradiotherapy (P = .004). In multivariable analysis, the use of preoperative chemoradiotherapy was associated with reduced risk of postoperative pancreatic fistula (odds ratio, 0.21; 95% confidence interval, 0.03-0.69; P = .033) compared with immediate surgery, whereas preoperative chemotherapy was not (odds ratio, 0.59; 95% confidence interval, 0.25-1.25; P = .199). Intraoperatively hard, or fibrotic pancreatic texture was most frequently observed after preoperative chemoradiotherapy (53% immediate surgery, 62% preoperative chemotherapy, 77% preoperative chemoradiotherapy, P < .001). CONCLUSION This nationwide analysis demonstrated that in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma, only preoperative chemoradiotherapy, but not preoperative chemotherapy, was associated with a reduced risk of postoperative pancreatic fistula.
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Affiliation(s)
- Leonoor V Wismans
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Jelle C van Dongen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, the Netherlands; Department of Medical Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, the Netherlands; Department of Radiation Oncology, Amsterdam UMC, location University of Amsterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, the Netherlands
| | - Joost J Nuyttens
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martijn P W Intven
- Department of Radiation Oncology, University Medical Center Utrecht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Medical Oncology, Maastricht University Medical Center, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands. http://www.twitter.com/MarcBesselink
| | - Casper H J van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Salcedo Mercado AM, Rodríguez Cabrero RA, Lozano Corona R, Anaya-Ayala JE. Durometry for the Assessment of Severity of Post-thrombotic Syndrome and Possible Clinical Applications. Vasc Endovascular Surg 2024; 58:54-59. [PMID: 37429286 DOI: 10.1177/15385744231189023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) impacts the patient's quality of life. Available scales to determine its severity remain controversial, therefore, it is of importance to identify new auxiliary methods for the assessment of this sequelae. Measurement of skin hardness (MSH) might be decisive in tracking PTS. The purpose of this study is to assess if the use of durometry is an objective measure to evaluate prognosis of affected limbs in patients with PTS. We compared MSH of extremities with PTS vs healthy limbs, as well as their variation after 3 months of medical treatment to evaluate if durometry can be used to find differences. We strongly believe that measuring and keeping track of skin changes specifically skin hardness can be a useful factor in the prognosis and treatment of PTS. METHODS Prospective cohort study from January 2021 to February 2022 in patients with unilateral PTS. The MSH of the affected limb was compared to the healthy limb. A calibrated durometer was used, 4 measurements were completed at the time of diagnosis and subsequent follow-up were carried out after 3 months of treatment. The percentage of healing (in case of ulcers) and adherence to treatment was carefully monitored. The statistical program R was used. RESULTS A total of 1088 durometric measurements were performed on 17 patients, and 34 limbs. The MSH in limbs with PTS was 39.09 and in the control limbs (19.8) (P = <.00001). After 3 months of treatment, the MSH in PTS varied in PTS limbs (39.09 to 30.4) (P = <.000012). Adherence to treatment was 70.5%. CONCLUSIONS MSH varied between healthy limbs and the ones with PTS, before and after treatment. Durometry might represent a method for assessing skin changes in patients with PTS.
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Affiliation(s)
| | | | | | - Javier E Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Jang JY, Chong EH, Kang I, Yang SJ, Lee SH, Choi SH. Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes. JOURNAL OF MINIMALLY INVASIVE SURGERY 2023; 26:72-82. [PMID: 37347100 PMCID: PMC10280110 DOI: 10.7602/jmis.2023.26.2.72] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023]
Abstract
Purpose Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR. Methods Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared. Results Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082). Conclusion Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.
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Affiliation(s)
- Jae Young Jang
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Eui Hyuk Chong
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Incheon Kang
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Seok Jeon Yang
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sung Hwan Lee
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sung Hoon Choi
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Mavroeidis VK, Russell TB, Clark J, Adebayo D, Bowles M, Briggs C, Denson J, Aroori S. Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity. Ann R Coll Surg Engl 2023; 105:446-454. [PMID: 35904332 PMCID: PMC10149251 DOI: 10.1308/rcsann.2022.0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/AIMS A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed. METHODS A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality. RESULTS Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131). CONCLUSIONS In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.
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Affiliation(s)
- VK Mavroeidis
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - TB Russell
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - J Clark
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - D Adebayo
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - M Bowles
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - C Briggs
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - J Denson
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - S Aroori
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
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Which one is better? Laparoscopic versus robotic reconstruction in the remnant soft pancreas with a small pancreatic duct following pancreaticoduodenectomy: a multicenter study with propensity score matching analysis. Surg Endosc 2022; 37:4028-4039. [PMID: 36097095 DOI: 10.1007/s00464-022-09602-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Evidence of the advantages of robotic pancreaticoduodenectomy (RPD) over laparoscopic pancreaticoduodenectomy (LPD) is limited. Thus, this study aimed to compare the surgical outcomes of laparoscopic reconstruction L-recon) versus robotic reconstruction (R-recon) in patients with soft pancreas and small pancreatic duct. METHOD Among 429 patients treated with minimally invasive pancreaticoduodenectomy (MIPD) between October 2012 and June 2020 by three surgeons at three institutions, 201 patients with a soft pancreas and a small pancreatic duct (< 3 mm) were included in this study. RESULTS Sixty pairs of patients who underwent L-recon and R-recon were selected after propensity score matching. The perioperative outcomes were comparable between the reconstruction approaches, with comparable clinically relevant postoperative pancreatic fistula (CR-POPF) rates (15.0% [L-recon] vs. 13.3% [R-recon]). The sub-analysis according to the type of MIPD procedure also showed comparable outcomes, but only a significant difference in postoperative hospital stay was identified. During the learning curve analysis using the cumulative summation by operation time (CUSUMOT), two surgeons who performed both L-recon and R-recon procedures reached their first peak in the CUSUMOT graph earlier for the R-recon group than for the L-recon group (i.e., 20th L-recon case and third R-recon case of surgeon A and 43rd L-recon case and seventh R-recon case of surgeon B). Surgeon C, who only performed R-recon, demonstrated the first peak in the 22nd case. The multivariate regression analysis for risk factors of CR-POPF showed that the MIPD procedure type, as well as other factors, did not have any significant effect. CONCLUSION Postoperative pancreatic fistula rates and the overall perioperative outcomes of L-recon and R-recon were comparable in patients with soft-textured pancreas and small pancreatic duct treated by experienced surgeons.
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Yamada H, Tanikawa M, Sakata T, Aihara N, Mase M. Usefulness of T2 Relaxation Time for Quantitative Prediction of Meningioma Consistency. World Neurosurg 2021; 157:e484-e491. [PMID: 34695610 DOI: 10.1016/j.wneu.2021.10.135] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Meningioma consistency is one of the most critical factors affecting the difficulty of surgery. Although many studies have attempted to predict meningioma consistency via magnetic resonance imaging findings, no definitive method has been established, because most have been based on qualitative evaluations. Therefore, the present study examined the potential of the T2 relaxation time (T2 value), a tissue-specific quantitative parameter, for assessment of meningioma consistency. METHODS Eighteen surgically treated meningiomas in 16 patients were included in the present study. Preoperatively, the T2 values of all meningiomas were calculated pixel by pixel, and a T2 value distribution map was generated. A total of 27 tumor specimens (multiple specimens were procured if heterogeneous) were taken from these meningiomas, with each localization identified intraoperatively using image guidance. The consistency of the specimens was measured with a durometer, originally a device for measuring the hardness of material such as elastic rubber, and their water content was subsequently measured using wet and dry measurements. RESULTS A significant correlation was found between the T2 values of the matched locations identified by image guidance intraoperatively and the consistency measured using the durometer (r = -0.722; P < 0.01) and the water content (r = 0.621; P = 0.01). In addition, the water content correlated significantly with the durometer consistency (r = -0.677; P < 0.01). CONCLUSIONS The T2 values could be a reliable quantitative predictor of meningioma consistency, and the T2 value distribution map, which elucidated the internal structure of the tumor in detail, could provide helpful information for surgical resection.
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Affiliation(s)
- Hiroshi Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan.
| | - Tomohiro Sakata
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Noritaka Aihara
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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Ju BJ, Jin M, Tian Y, Zhen X, Kong DX, Wang WL, Yan S. Model for liver hardness using two-dimensional shear wave elastography, durometer, and preoperative biomarkers. World J Gastrointest Surg 2021; 13:127-140. [PMID: 33643533 PMCID: PMC7898182 DOI: 10.4240/wjgs.v13.i2.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/27/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) increases morbidity and mortality after liver resection for patients with advanced liver fibrosis and cirrhosis. Preoperative liver stiffness using two-dimensional shear wave elastography (2D-SWE) is widely used to evaluate the degree of fibrosis. However, the 2D-SWE results were not accurate. A durometer measures hardness by quantifying the ability of a material to locally resist the intrusion of hard objects into its surface. However, the durometer score can only be obtained during surgery.
AIM To measure correlations among 2D-SWE, palpation by surgeons, and durometer-measured objective liver hardness and to construct a liver hardness regression model.
METHODS We enrolled 74 hepatectomy patients with liver hardness in a derivation cohort. Tactile-based liver hardness scores (0-100) were determined through palpation of the liver tissue by surgeons. Additionally, liver hardness was measured using a durometer. Correlation coefficients for durometer-measured hardness and preoperative parameters were calculated. Multiple linear regression models were constructed to select the best predictive durometer scale. Receiver operating characteristic (ROC) curves and univariate and multivariate analyses were used to calculate the best model’s prediction of PHLF and risk factors for PHLF, respectively. A separate validation cohort (n = 162) was used to evaluate the model.
RESULTS The stiffness measured using 2D-SWE and palpation scale had good linear correlation with durometer-measured hardness (Pearson rank correlation coefficient 0.704 and 0.729, respectively, P < 0.001). The best model for the durometer scale (hardness scale model) was based on stiffness, hepatitis B virus surface antigen, and albumin level and had an R2 value of 0.580. The area under the ROC for the durometer and hardness scale for PHLF prediction were 0.807 (P = 0.002) and 0.785 (P = 0.005), respectively. The optimal cutoff value of the durometer and hardness scale was 27.38 (sensitivity = 0.900, specificity = 0.660) and 27.87 (sensitivity = 0.700, specificity = 0.787), respectively. Patients with a hardness scale score of > 27.87 were at a significantly higher risk of PHLF with hazard ratios of 7.835 (P = 0.015). The model’s PHLF predictive ability was confirmed in the validation cohort.
CONCLUSION Liver stiffness assessed by 2D-SWE and palpation correlated well with durometer hardness values. The multiple linear regression model predicted durometer hardness values and PHLF.
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Affiliation(s)
- Bing-Jie Ju
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
| | - Ming Jin
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
| | - Yang Tian
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
| | - Xiang Zhen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
| | - De-Xing Kong
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- School of Mathematical Sciences, Zhejiang University, Hangzhou 310027, Zhejiang Province, China
| | - Wei-Lin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
| | - Sheng Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, Zhejiang Province, China
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Research Center of Diagnosis and Treatment Technology for Hepatocellular Carcinoma of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
- Clinical Medicine Innovation Center of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Disease of Zhejiang University, Hangzhou 310009, Zhejiang Province, China
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310009, Zhejiang Province, China
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A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. Surgery 2020; 169:1471-1479. [PMID: 33390302 DOI: 10.1016/j.surg.2020.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND We investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. METHODS We investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography. RESULTS One hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m2) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤-3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019-5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m2 vs 19.6 kg/m2; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (-9.6 Hounsfield units vs -4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively. CONCLUSION Deep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.
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Abstract
Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.
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Hank T, Sandini M, Fernández-del Castillo C. Prognostic Value of Pancreatic Fistula in Resected Patients With Pancreatic Cancer With Neoadjuvant Therapy—Reply. JAMA Surg 2020; 155:269. [DOI: 10.1001/jamasurg.2019.5091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
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Nichols CW, Brismée JM, Hooper TL, Bertrand-Grenier A, Gilbert KK, St-Pierre MO, Kapila J, Sobczak S. Glenohumeral joint capsular tissue tension loading correlates moderately with shear wave elastography: a cadaveric investigation. Ultrasonography 2019; 39:114-120. [PMID: 31786904 PMCID: PMC7065991 DOI: 10.14366/usg.19032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/01/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose The purpose of this study was to investigate changes in the mechanical properties of capsular tissue using shear wave elastography (SWE) and a durometer under various tensile loads, and to explore the reliability and correlation of SWE and durometer measurements to evaluate whether SWE technology could be used to assess tissue changes during capsule tensile loading. Methods The inferior glenohumeral joint capsule was harvested from 10 fresh human cadaveric specimens. Tensile loading was applied to the capsular tissue using 1-, 3-, 5-, and 8-kg weights. Blinded investigators measured tissue stiffness and hardness during loading using SWE and a durometer, respectively. Intraobserver reliability was established for SWE and durometer measurements using intraclass correlation coefficients (ICCs). The Pearson product-moment correlation was used to assess the associations between SWE and durometer measurements. Results The ICC3,5 for durometer measurements was 0.90 (95% confidence interval [CI], 0.79 to 0.96; P<0.001) and 0.95 (95% CI, 0.88 to 0.98; P<0.001) for SWE measurements. The Pearson correlation coefficient values for 1-, 3-, and 5-kg weights were 0.56 (P=0.095), 0.36 (P=0.313), and -0.56 (P=0.089), respectively. When the 1- and 3-kg weights were combined, the ICC3,5 was 0.72 (P<0.001), and it was 0.62 (P<0.001) when the 1-, 3-, and 5-kg weights were combined. The 8-kg measurements were severely limited due to SWE measurement saturation of the tissue samples. Conclusion This study suggests that SWE is reliable for measuring capsular tissue stiffness changes in vitro at lower loads (1 and 3 kg) and provides a baseline for the non-invasive evaluation of effects of joint loading and mobilization on capsular tissues in vivo.
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Affiliation(s)
- Charles W Nichols
- Department of Physical Therapy, School of Health Professions, University of North Texas Health Science Center, Ft. Worth, TX, USA
| | - Jean-Michel Brismée
- Department of Rehabilitation Sciences, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Troy L Hooper
- Department of Rehabilitation Sciences, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Antony Bertrand-Grenier
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS MCQ), TroisRivières, Québec, Canada.,Centre Hospitalier Affilié Universitaire Régional, Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS MCQ), Trois-Rivières, Québec, Canada.,Département de Chimie, Biochimie et Physique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Kerry K Gilbert
- Department of Rehabilitation Sciences, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Marc-Olivier St-Pierre
- Département d'Anatomie, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Jeegisha Kapila
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Stéphane Sobczak
- Département d'Anatomie, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada.,Unité de Recherche en Anatomie Clinique et Fonctionnelle (URACEF), Trois-Rivires, Québec, Canada
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Gonzalez-Heredia R, Durgam S, Masrur M, Gonzalez-Ciccarelli LF, Gangemi A, Bianco FM, Giulianotti PC. Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy. Gastrointest Tumors 2019; 5:68-76. [PMID: 30976577 DOI: 10.1159/000489777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background Various technical improvements have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. The aim of this study was to identify the risk factors and incidence of POPF with different types of pancreatic stump management after robot-assisted pancreaticoduodenectomy (RAPD). Materials and Methods This study is a retrospective review of consecutive patients who underwent RAPD at the University of Illinois Hospital and Health Sciences System between September 2007 and January 2016. The cohort was divided based on the type of pancreatic stump management: pancreatic duct occlusion with cyanoacrylate glue (CG), pancreaticojejunostomy (PJ), posterior pancreaticogastrostomy (PPG), and transgastric pancreaticogastrostomy (TPG). Results The cohort included 69 patients: pancreatic duct occlusion with CG (n = 18), PJ (n = 12), PPG (n = 11), and TPG (n = 28). Pancreatic duct diameter < 3 mm and duct occlusion with CG were identified as risk factors for POPF (p < 0.05). The incidence of POPF was lower when TPG and PJ were performed (p < 0.001). Conclusions Reconstruction with PJ and TPG had better results compared to pancreatic duct occlusion with CG and PPG. However, TPG was the technique of choice and showed comparable results to PJ.
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Affiliation(s)
- Raquel Gonzalez-Heredia
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Samarth Durgam
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mario Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Luis Fernando Gonzalez-Ciccarelli
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pier C Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Risk stratification for postoperative pancreatic fistula using the pancreatic surgery registry StuDoQ|Pancreas of the German Society for General and Visceral Surgery. Pancreatology 2019; 19:17-25. [PMID: 30563791 DOI: 10.1016/j.pan.2018.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/02/2018] [Accepted: 11/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a major factor for morbidity and mortality after pancreatic resection. Risk stratification for POPF is important for adjustment of treatment, selection of target groups in trials and quality assessment in pancreatic surgery. In this study, we built a risk-prediction model for POPF based on a large number of predictor variables from the German pancreatic surgery registry StuDoQ|Pancreas. METHODS StuDoQ|Pancreas was searched for patients, who underwent pancreatoduodenectomy from 2014 to 2016. A multivariable logistic regression model with elastic net regularization was built including 66 preoperative und intraoperative parameters. Cross-validation was used to select the optimal model. The model was assessed via area under the ROC curve (AUC) and calibration slope and intercept. RESULTS A total of N = 2488 patients were included. In the optimal model the predictors selected were texture of the pancreatic parenchyma (soft versus hard), body mass index, histological diagnosis pancreatic ductal adenocarcinoma and operation time. The AUC was 0.70 (95% CI 0.69-0.70), the calibration slope 1.67 and intercept 1.12. In the validation set the AUC was 0.65 (95% CI 0.64-0.66), calibration slope and intercept were 1.22 and 0.42, respectively. CONCLUSION The model we present is a valid measurement instrument for POPF risk based on four predictor variables. It can be applied in clinical practice as well as for risk-adjustment in research studies and quality assurance in surgery.
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Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 2018; 20:992-1003. [PMID: 29807807 DOI: 10.1016/j.hpb.2018.04.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/09/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive. METHODS A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition. RESULTS 122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT. CONCLUSION The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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21
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Aghalarov I, Herzog T, Uhl W, Belyaev O. A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients. HPB (Oxford) 2018; 20:676-683. [PMID: 29456198 DOI: 10.1016/j.hpb.2018.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Double-loop (DL) reconstruction after pancreaticoduodenectomy (PD), diverting pancreatic from biliary secretions, has been reported to reduce rates and severity of postoperative pancreatic fistula (POPF) compared to single loop (SL) reconstruction at the price of prolonged operative duration. This study investigated the feasibility of a new reconstruction method combining the advantages of DL with the simplicity of SL in patients with high-risk pancreas. METHODS A modified single-loop (mSL) reconstruction was used in patients undergoing PD with a soft pancreatic remnant and a pancreatic duct smaller than 3 mm (n = 50). The loop between the pancreatic and the biliary anastomoses was left longer and a side-to-side jejunojejunal anastomosis was performed between them at the lowest point to promote isolated flow of pancreatic and biliary secretions. Rate and severity of POPF, mortality, duration of surgery, and POPF-associated morbidity were compared to those of 50 matched patients with SL and 25 patients with DL reconstruction. RESULTS Duration of surgery was 57 min longer for DL, but equal for mSL and SL. The POPF rate did not differ between the three groups. The severity of POPF was more pronounced in the SL group (62% grade C: p = 0.011). Mortality and major morbidity were lower and hospital stay shorter in the mSL and DL groups compared to the SL group. CONCLUSIONS The new mSL reconstruction was safer than conventional SL and faster to perform than DL reconstruction in patients with a high-risk pancreas. It did not influence the rate of POPF, but reduced its severity, leading to less major morbidity and mortality.
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Affiliation(s)
- Ilgar Aghalarov
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany.
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Stärke C, Lohmann CH, Kopf S. Stiffness of meniscus tissue depends on tibio-femoral load and structural integrity of the meniscus root. Proc Inst Mech Eng H 2018; 232:418-422. [PMID: 29475414 DOI: 10.1177/0954411918759802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Development of meniscus replacements requires in-depth knowledge of the material properties and biomechanical behavior of the native meniscus. The compressive properties are of particular interest in this context, which are often assessed with indentation tests. However, those tests are usually done on isolated tissue specimens ex situ, which could have a significant impact on the results. It was, therefore, the goal of the study to assess the stiffness of the meniscus tissue in situ in porcine specimens and to compare it to that of artificial substitutes. Porcine knees (n = 8) were prepared such that the medial meniscus periphery was exposed and the knees could be mounted in a materials testing machine. The tissue stiffness was than measured on the meniscus periphery using a Shore-A durometer in (1) the unloaded knee, (2) with 500-N tibio-femoral compressive load, and (3) with 500-N tibio-femoral load and the posterior meniscus root detached. The stiffness of the meniscus tissue was significantly increased when tibio-femoral load was applied, while this effect was lost when the meniscus root was cut (average measurements on a 0-100 Shore-A durometer scale: group A, 33.8; group B, 58.4; and group C, 36.2). Polyurethane and collagen meniscus implants showed an inferior stiffness compared to the native meniscus. These findings might be relevant for the material choice in artificial meniscus replacements and the fixation of allografts. Biomechanical testing of isolated tissue specimens could underestimate the effective meniscus tissue stiffness compared to a physiological joint environment.
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Affiliation(s)
- Christian Stärke
- 1 Department of Orthopaedic Surgery, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | | | - Sebastian Kopf
- 2 Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
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23
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Giulianotti PC, Gonzalez-Heredia R, Esposito S, Masrur M, Gangemi A, Bianco FM. Trans-gastric pancreaticogastrostomy reconstruction after pylorus-preserving robotic Whipple: a proposal for a standardized technique. Surg Endosc 2017; 32:2169-2174. [DOI: 10.1007/s00464-017-5916-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023]
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24
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Egorov VI, Petrov RV. [Simple and reliable pancreatoenteroanastomosis]. Khirurgiia (Mosk) 2017:60-68. [PMID: 29186099 DOI: 10.17116/hirurgia20171160-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- V I Egorov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
| | - R V Petrov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
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25
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Yoon YC, Lee JS, Park SU, Kwon JH, Hong TH, Kim DG. Quantitative assessment of liver fibrosis using shore durometer. Ann Surg Treat Res 2017; 93:300-304. [PMID: 29250508 PMCID: PMC5729123 DOI: 10.4174/astr.2017.93.6.300] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/22/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose of the present study was to investigate whether hardness of liver surface correlated with degree of liver fibrosis, and its association with posthepatectomy liver failure (PHLF). Methods A shore durometer was used to measure hepatic hardness in 41 patients with hepatocellular carcinoma (HCC) and in 10 patients with normal liver. We investigated how hepatic hardness correlates with various values indicating the degree of liver fibrosis, and how it correlates with PHLF. Results In the normal liver group, the surface shore units (SU) was 15.06 ± 2.64. In the HCC group, there was a correlation between surface SU and preoperative results indicating liver fibrosis. Among patients with PHLF after resecting over 3 segments, the surface SU of patients with grade A PHLF was 21.85 ± 5.63, and the surface SU of patients with grade C PHLF was 35.75 ± 9.26. In patients with PHLF after resecting 2 or less segments, the surface SU of patients with PHLF grade A was 20.95 ± 5.18, and the surface SU of patients with PHLF grade B was 31.60 ± 5.57. In predicting PHLF, surface SU was more effective than preoperative platelet count, spleen volume, or liver fibrosis index. Conclusion Hepatic hardness measured by the shore durometer was correlated with the degree of liver fibrosis. Liver surface SU was a more effective parameter for predicting PHLF, as compared to other indicators evaluated before hepatectomy. The decision to perform major hepatectomy should be reconsidered in cases with a liver surface SU of >30.
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Affiliation(s)
- Young Chul Yoon
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Jun Suh Lee
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Sang Uk Park
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Jung Hyun Kwon
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Tae Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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26
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Casadei R, Ricci C, Taffurelli G, Pacilio CA, Di Marco M, Pagano N, Serra C, Calculli L, Santini D, Minni F. Prospective validation of a preoperative risk score model based on pancreatic texture to predict postoperative pancreatic fistula after pancreaticoduodenectomy. Int J Surg 2017; 48:189-194. [PMID: 28987563 DOI: 10.1016/j.ijsu.2017.09.070] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/25/2017] [Accepted: 09/29/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND In 2015, basing on objective preoperative factors related to pancreas remnant texture (body mass index, Wirsung duct size and preoperative diagnosis), we proposed a score model to predict the risk of postoperative pancreatic fistula after partial pancreatectomies. The aim of the present study was to prospectively validate this preoperative predictive risk score for postoperative pancreatic fistula after pancreaticoduodenectomy. METHODS Prospective study of consecutive patients who underwent pancreaticoduodenectomy in which a preoperative risk score, based on factors related to the pancreatic texture, was calculated. The risk score model was tested by comparison with subjective intraoperative assessment of the pancreas remnant texture and drain amylase value on postoperative day 1. Sensitivity, specificity, positive and negative likelihood ratio and area under the curve were calculated. RESULTS Eighty-four patients who underwent pancreaticoduodnectomy were analyzed. Clinically relevant pancreatic fistulas rate was 40.6%. The risk score model with a cut-off of 6 increased the odds of pancreatic fistula approximately 3 fold but it was not independently related to it. On the contrary, considering a cut-off of 5, the risk score model increased the odds of pancreatic fistula 11-16 fold and it was independently related to it. The new risk score model and pancreatic texture had high sensitivity (97% and 88%, respectively) and low specificity (34% and 60%, respectively) while the amylase drain value had low sensitivity (44%) and high specificity (92%). CONCLUSIONS The preoperative risk score model with a cut-off of 5 was a useful predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy. The drain amylase value represents a complementary factor to the risk score in predicting a pancreatic fistula.
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Affiliation(s)
- Riccardo Casadei
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy.
| | - Claudio Ricci
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Giovanni Taffurelli
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Carlo Alberto Pacilio
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Mariacristina Di Marco
- Department of Specialist, Diagnostic and Experimental Medicine (DIMES), S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Nico Pagano
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Carla Serra
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Lucia Calculli
- Department of Specialist, Diagnostic and Experimental Medicine (DIMES), S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Donatella Santini
- Department of Specialist, Diagnostic and Experimental Medicine (DIMES), S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Francesco Minni
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
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Marchegiani G, Ballarin R, Malleo G, Andrianello S, Allegrini V, Pulvirenti A, Paini M, Secchettin E, Boriero F, Di Benedetto F, Bassi C, Salvia R. Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula. World J Surg 2017; 41:2876-2883. [DOI: 10.1007/s00268-017-4073-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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28
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Hong TH, Choi JI, Park MY, Rha SE, Lee YJ, You YK, Choi MH. Pancreatic hardness: Correlation of surgeon’s palpation, durometer measurement and preoperative magnetic resonance imaging features. World J Gastroenterol 2017; 23:2044-2051. [PMID: 28373771 PMCID: PMC5360646 DOI: 10.3748/wjg.v23.i11.2044] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/15/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the correlation between subjective assessments of pancreatic hardness based on the palpation, objective measurements using a durometer, and magnetic resonance imaging (MRI) findings for assessing pancreatic hardness.
METHODS Eighty-three patients undergoing pancreatectomies were enrolled. An experienced surgeon subjectively evaluated the pancreatic hardness in the surgical field by palpation. The pancreatic hardness was also objectively evaluated using a durometer. Preoperative MRI findings were evaluated by a radiologist in terms of the apparent diffusion coefficient (ADC) values, the relative signal intensity decrease (RSID) of the pancreatic parenchyma, and the diameter of the pancreatic parenchyma and duct. Durometer measurement results, ADC values, RSID, pancreatic duct and parenchyma diameters, and the ratio of the diameters of the duct and parenchyma were compared between pancreases judged to be soft or hard pancreas on the palpation. A correlation analysis was also performed between the durometer and MRI measurements.
RESULTS The palpation assessment classified 44 patients as having a soft pancreas and 39 patients as having a hard pancreas. ADC values were significantly lower in the hard pancreas group. The ductal diameter and duct-to-pancreas ratio were significantly higher in the hard pancreas group. For durometer measurements, a correlation analysis showed a positive correlation with the ductal diameter and the duct-to-pancreas ratio and a negative correlation with ADC values.
CONCLUSION Hard pancreases showed lower ADC values, a wider pancreatic duct diameter and a higher duct-to-pancreas ratio than soft pancreases. Additionally, the ADC values, diameter of the pancreatic duct and duct-to-pancreas ratio were closely correlated with the durometer results.
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Mikamori M, Gotoh K, Takahashi H, Akita H, Tomokuni A, Kobayashi S, Ohue M, Fujiwara Y, Yano M, Ishikawa O, Sakon M. Novel intraoperative use of the "Tensipresser" to assess factors predictive of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2017; 47:1201-1207. [PMID: 28324164 DOI: 10.1007/s00595-017-1509-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
PURPOSES Pancreatic fistula (PF) is a challenging complication of pancreaticoduodenectomy (PD). 'Soft pancreas' is reported as a risk factor for PF; however, palpation by the surgeon is not an objective method of evaluating pancreatic texture. We conducted this study to investigate whether a texture analyzer called a "Tensipresser" can be used to quantify pancreatic tissue hardness and predict the development of postoperative PF. METHODS We assessed pancreatic texture in 85 patients who underwent PD. After surgeons assessed the texture of the pancreas subjectively, the physical properties were measured on the pancreatic margin intraoperatively, by the two-bite method using the "Tensipresser". The incidence and severity of PF were based on the definitions of the International Study Group on Pancreatic Fistula. RESULTS Symptomatic PF (grade B and C) developed in 16% of the patients. Patients were divided into two groups based on the Tensipresser measurement: those with a soft and fragile pancreas with hardness < 2070 gw/cm2 and cohesiveness < 0.65 (SF group); and all other patients (non-SF group). In the univariate and multivariate analysis, a small pancreatic duct diameter (<4 mm), no conduction of preoperative chemoradiation therapy, and inclusion in the SF group were significant predictors of PF. CONCLUSION The Tensipresser can evaluate pancreatic texture objectively, helping to define intraoperatively, those at risk of the development of PF.
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Affiliation(s)
- Manabu Mikamori
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
- Department of Gastroenterological Surgery, Graduate School of Medicine Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Kunihito Gotoh
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan.
- Department of Gastroenterological Surgery, Graduate School of Medicine Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidenori Takahashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Hirofumi Akita
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Akira Tomokuni
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Shogo Kobayashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masahiko Yano
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Osamu Ishikawa
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
| | - Masato Sakon
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Nakamichi 1-3-3, Higashinari-ku, Osaka, 537-0025, Japan
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Kiyochi H. Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy: Reply. World J Surg 2017; 39:2967-74. [PMID: 26732669 DOI: 10.1007/s00268-015-3211-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Shin DS, Kang SH, Kim DS, Kim TH, Kim KH, Koo HJ, Cho MS, Ha JS, Yoon DK, Suh TS. Development of an Advanced Deformable Phantom to Analyze Dose Differences due to Respiratory Motion. ACTA ACUST UNITED AC 2017. [DOI: 10.14316/pmp.2017.28.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Dong-Seok Shin
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong-Hee Kang
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Su Kim
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae-Ho Kim
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyeong-Hyeon Kim
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun-Jae Koo
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min-Seok Cho
- Department of Radiation Oncology, Asan Medical Center, Seoul, Korea
| | - Jin-Suk Ha
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Radiation Oncology, Gangnam Severance Hospital, Seoul, Korea
| | - Do-Kun Yoon
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Suk Suh
- Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial. Ann Surg 2016; 263:440-9. [PMID: 26135690 PMCID: PMC4741417 DOI: 10.1097/sla.0000000000001240] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives: To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial. Background: PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications. Methods: A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up. Results: From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters. Conclusions: The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.
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Belyaev O, Polle C, Herzog T, Munding J, Chromik AM, Meurer K, Tannapfel A, Bergmann U, Müller CA, Uhl W. Effects of intra-arterial octreotide on pancreatic texture: a randomized controlled trial. Scand J Surg 2015; 102:164-70. [PMID: 23963030 DOI: 10.1177/1457496913490457] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Octreotide is suggested to harden the pancreas, thus facilitating the construction of a pancreatic anastomosis and lowering the risk of postoperative fistula. We tested the hypothesis that intra-arterial application of octreotide in the gastroduodenal artery during pancreatectomy may increase pancreatic hardness. MATERIAL AND METHODS A single-center, prospective, double-blinded, randomized controlled trial with parallel assignment was conducted. Patients planned for a pancreatoduodenectomy or a total pancreatectomy, who had a palpatory and durometer proven (<40 Shore units) soft pancreas, were assigned to receive intraoperatively either 5 mL 500µg octreotide or 5 mL 0.9% saline solution as a bolus injection in the gastroduodenal artery. Pancreatic hardness was measured before, early, and late after intervention. The investigator performing the durometer measurements and pathologist were masked to group assignment. The primary outcome was increased pancreatic hardness. Analysis was by intention to treat. This trial is registered at http://www.clinicaltrials.gov (ID NCT01400100). RESULTS A total of 12 patients received octreotide and 13 received saline solution. Pancreatic hardness marginally increased in the octreotide group: 0.67 ± 2.3 Shore units, whereas it decreased in the control group: -2.15 ± 2.7 Shore units. The difference was statistically significant, p = 0.029 (95% confidence interval = -4.87 to -0.77). Histology did not find any correlate for this clinically irrelevant hardening effect. CONCLUSIONS A single bolus application of octreotide did not deliver a clinically relevant increase in pancreatic hardness. Future studies on the hardening effect of octreotide should employ repeated or continuous preoperative administration of this drug.
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Affiliation(s)
- O Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
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Kim EY, You YK, Kim DG, Hong TH. A simple pancreaticojejunostomy technique for hard pancreases using only two transpancreatic sutures with buttresses: a comparison with the previous pancreaticogastrostomy and dunking methods. Ann Surg Treat Res 2015; 90:64-71. [PMID: 26878013 PMCID: PMC4751147 DOI: 10.4174/astr.2016.90.2.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/28/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE In this study, we introduced a novel technique, the pancreaticojejunostomy (PJ), which uses only two transpancreatic sutures with buttresses (PJt), and compared the surgical outcomes with previously used methods, especially for hard pancreases. METHODS A total of 101 patients who underwent pancreaticoduodenectomy with hard pancreases were enrolled and divided into 3 groups according to the method of pancreaticoenteric anastomosis: 30 patients (29.7%) underwent the conventional dunking method (Du), 31 patients (30.7%) underwent pancreaticogastrostomy using transpancreatic sutures (PGt) and 40 patients (39.6%) underwent PJ using transpancreatic sutures (PJt). The surgical outcomes were compared according to the type of anastomosis to analyze the feasibility and ease of each technique. RESULTS The overall operative time was shorter in the PJt group (325.1 ± 63.8 minutes) than in the PGt group (367.3 ± 70.5 minutes) or the Du group (412.0 ± 38.2 minutes, P < 0.001). In terms of pancreaticoenteric anastomosis time, it was also shorter in the PJt group (10.3 ± 3.5 minutes) than in the Du group (20.7 ± 0.7 minutes) or the PGt group (16.8 ± 5.4 minutes, P = 0.005). Significant postoperative pancreatic fistula (POPF) developed in 2 cases (6.7%) in the Du group, whereas there were no POPF cases in the PGt or PJt groups (P = 0.086). Overall postoperative morbidities occurred in 31 cases (30.7%), and there were no significant differences among the 3 groups (P = 0.692). CONCLUSION The novel PJ technique, which uses only two transpancreatic sutures with buttresses, is a very simple, easy and secure method for hard pancreases and can be performed in a shorter amount of time compared with conventional methods.
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Affiliation(s)
- Eun Young Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Atema JJ, Jilesen APJ, Busch ORC, van Gulik TM, Gouma DJ, van Dijkum EJMN. Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions. HPB (Oxford) 2015; 17:38-45. [PMID: 25041879 PMCID: PMC4266439 DOI: 10.1111/hpb.12319] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/18/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection for pancreatic neuroendocrine tumours (PNET) is suggested to be associated with an increased risk of a post-operative pancreatic fistula (POPF). The aim of this study was to describe morbidity after resections for PNET, focusing on POPF. Outcomes were compared with resections for other lesions. METHODS Patients undergoing an elective pancreatic resection during a 12-year period were retrospectively analysed. Morbidity was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definitions. RESULTS Eighty-eight out of 832 patients (10.6%) underwent a resection for PNET. Atypical pancreatic resections (enucleation and central pancreatectomy) and distal pancreatectomies were more frequently performed for PNET. The POPF rate was 22.7% in patients operated for PNET compared with 17.2% in other patients (P = 0.200). In univariate analysis, body mass index (BMI), pancreatic duct diameter, somatostatin analogue administration, type of resection and type of pathology were associated with a POPF. In multivariate analysis, BMI, a pancreatic duct diameter <3 mm and central pancreatectomy remained independent risk factors [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22-3.07 and OR 3.04, 95% CI 1.05-8.82, respectively]. CONCLUSIONS High rates of POPF were found in patients operated for PNET. However, this was mainly owing to the fact that atypical resections, known to be associated with a higher fistula rate, were performed more frequently in these patients.
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Affiliation(s)
| | | | | | | | | | - Els J M Nieveen van Dijkum
- Correspondence, Els J.M. Nieveen van Dijkum, Department of Surgery, Academic Medical Center, Meibergdreef 9; PO Box 22660, 1105 AZ Amsterdam, The Netherlands. Tel: +31 20 566 3067. Fax: +31 20 566 2659. E-mail:
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Casadei R, Ricci C, Taffurelli G, D'Ambra M, Pacilio CA, Ingaldi C, Minni F. Are there preoperative factors related to a "soft pancreas" and are they predictive of pancreatic fistulas after pancreatic resection? Surg Today 2014; 45:708-14. [PMID: 25331230 DOI: 10.1007/s00595-014-1045-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/14/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistula. We conducted this study to clarify if there are preoperative factors related to a soft pancreatic remnant and to establish if they are useful for predicting pancreatic fistula. METHODS This was a retrospective study of patients who underwent pancreatic resections at the Department of Surgical Sciences of the S. Orsola-Malpighi Hospital, Bologna, Italy. The factors considered were sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, characteristics of the pancreatic remnant, and preoperative diagnosis. RESULTS Data from 208 patients were recorded. The risk factors predictive of a soft pancreatic remnant were BMI >24 kg/m(2) (P = 0.011), a Wirsung duct size ≤3 mm (P < 0.001), and coexisting periampullary diseases (P < 0.001). Using these factors, we developed a risk score model that was validated by considering the pancreatic fistula rate. The overall and clinically relevant pancreatic fistula rate increased with increasing score values (P = 0.002 and P = 0.028, respectively). Using a score cut-off value of six points, patients with a score ≥6 were considered to be at high risk. CONCLUSIONS Body mass index >24 kg/m(2), a Wirsung duct size <3 mm, and preoperative diagnosis represented the preoperative factors related to a soft pancreas. These factors proved useful in the building of a risk score model to predict the incidence of pancreatic fistula.
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Affiliation(s)
- Riccardo Casadei
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Università di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n.9, 40138, Bologna, Italy,
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Hybrid laparoscopic versus open pylorus-preserving pancreatoduodenectomy: retrospective matched case comparison in 80 patients. Langenbecks Arch Surg 2014; 399:849-56. [PMID: 25074409 DOI: 10.1007/s00423-014-1236-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/23/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE We compared the outcome of hybrid laparoscopic pylorus-preserving pancreatoduodenectomy (lapPPPD) and open PPPD (oPPPD) in a retrospective case-matched study. METHODS Patients operated from 2010 to 2013 by lapPPPD were matched 1:1 for age, sex, histopathology, American Society of Anesthesiologists category and body mass index to oPPPD patients operated from 1996 to 2013. RESULTS Patients eligible for lapPPPD are a risk group due to a high rate of soft pancreata. Complication rate and mortality were comparable to oPPPD. There was a significantly reduced transfusion requirement and a trend towards shorter operation time, less delayed gastric emptying, and reduced hospital stay. The main reason for conversion was portal venous tumor adhesion. Patient selection changed and operation time and hospital stay decreased with the surgeons' experience. CONCLUSION In selected patients, a hybrid laparoscopic technique of pancreatoduodenectomy is feasible with complication rates comparable to the open procedure. There seem to be advantages in terms of transfusion requirement, operation time, and hospital stay.
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Morphohistological features of pancreatic stump are the main determinant of pancreatic fistula after pancreatoduodenectomy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:641239. [PMID: 24900974 PMCID: PMC4036600 DOI: 10.1155/2014/641239] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/19/2014] [Indexed: 01/08/2023]
Abstract
Introduction. Pancreatic surgery is challenging and associated with high morbidity, mainly represented by postoperative pancreatic fistula (POPF) and its further consequences. Identification of risk factors for POPF is essential for proper postoperative management. Aim of the Study. Evaluation of the role of morphological and histological features of pancreatic stump, other than main pancreatic duct diameter and glandular texture, in POPF occurrence after pancreaticoduodenectomy. Patients and Methods. Between March 2011 and April 2013, we performed 145 consecutive pancreaticoduodenectomies. We intraoperatively recorded morphological features of pancreatic stump and collected data about postoperative morbidity. Our dedicated pathologist designed a score to quantify fibrosis and inflammation of pancreatic tissue. Results. Overall morbidity was 59,3%. Mortality was 4,1%. POPF rate was 28,3%, while clinically significant POPF were 15,8%. Male sex (P = 0.009), BMI ≥ 25 (P = 0.002), prolonged surgery (P = 0.001), soft pancreatic texture (P < 0.001), small pancreatic duct (P < 0.001), pancreatic duct decentralization on stump anteroposterior axis, especially if close to the posterior margin (P = 0.031), large stump area (P = 0.001), and extended stump mobilization (P = 0.001) were related to higher POPF rate. Our fibrosis-and-inflammation score is strongly associated with POPF (P = 0.001). Discussion and Conclusions. Pancreatic stump features evaluation, including histology, can help the surgeon in fitting postoperative management to patient individual risk after pancreaticoduodenectomy.
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Shin HW, Kim JK, Park JS, Yoon DS. Can we predict postoperative pancreatic leakage after pancreaticoduodenectomy using preoperative fecal elastase-1 level? J Clin Lab Anal 2014; 27:379-83. [PMID: 24038223 DOI: 10.1002/jcla.21614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 03/27/2013] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION The measurement of fecal elastas-1 in stools is a sensitive and relatively inexpensive noninvasive test. The aim of this study was to study fecal elastase levels in patients who develop pancreatic leakage after pancreaticoduodenectomy (PD) to determine if fecal elastase level can be used to predict patients at high risk for pancreatic leakage after PD. METHODS Pancreatic function was considered normal when fecal elastase-1 concentration exceeded 200 μg/g feces and moderately or severely insufficient when fecal elastas-1 concentration was less than 200 μg/g feces. RESULTS Of 123 patients who underwent PD, 67 (54.5%) showed fecal elastase-1 levels less than 200 μg/g, indicating moderate or severe pancreatic insufficiency. Pancreas texture, pathology origin, and level of γ-glutamyl transferase (r-GT) were significantly correlated with fecal elastas-1 level. On univariate analysis, the incidence of pancreatic leakage was significantly greater in the group with normal fecal elastase-1 level (≥200 μg/g), pathologic origin (bile duct/ampulla/duodenum), and soft pancreas texture. In multivariate analysis, normal fecal elastase-1 level (≥200 μg/g) and soft pancreatic texture were identified as independent factors for pancreatic leakage. CONCLUSIONS Fecal elastase-1 is the most simple and objective method for predicting pancreatic leakage after PD.
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Affiliation(s)
- Hyun Wook Shin
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, Korea
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Belyaev O, Rosenkranz S, Munding J, Herzog T, Chromik AM, Tannapfel A, Uhl W. Quantitative assessment and determinants of suture-holding capacity of human pancreas. J Surg Res 2013; 184:807-12. [PMID: 23663821 DOI: 10.1016/j.jss.2013.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 03/24/2013] [Accepted: 04/05/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hard pancreas is welcome by surgeons performing resective pancreatic surgery, because it is believed to offer better suture holding capacity (SHC), thus decreasing the risk for a postoperative leak. However, neither the actual SHC of pancreatic tissue in humans nor its determinants have been studied. METHODS We directly measured SHC for polydioxanone 5-0 suture and tissue hardness at the pancreatic isthmus in 53 human pancreata using a dynamometer and a durometer. A histologic score based on fibrosis grade, fat content, pancreatic duct size, and signs of chronic pancreatitis was calculated for every sample. We tested the hypothesis that SHC of the pancreas was proportional to tissue hardness, and evaluated the role of different possible histomorphologic determinants of SHC. RESULTS Suture-holding capacity correlated perfectly with tissue hardness (r = 0.98; P < 0.001; 95% confidence interval, 0.96-0.99). The histologic score showed a stronger correlation with both parameters than any single histologic parameter. The SHC of transductal sutures was significantly higher than that of pure transparenchymal sutures. The SHC and hardness were significantly lower in patients who developed a clinically relevant pancreatic fistula postoperatively. CONCLUSIONS A mixture of histomorphologic features of human pancreas determines its tissue hardness and SHC. Involvement of the main pancreatic duct in the suture line appears to increase the mechanical strength of the pancreatic anastomosis.
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Affiliation(s)
- Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany.
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Re: "Impact of age over 75 years on outcomes after pancreaticoduodenectomy". J Surg Res 2013; 187:718-9. [PMID: 23453754 DOI: 10.1016/j.jss.2013.01.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 01/10/2013] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
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Abstract
OBJECTIVE The aims of this study were to clarify the type of intrapancreatic spread of cancer of the pancreatic body and tail and to assess whether a 2-cm transection margin is adequate to ensure negative margins. METHODS We selected 66 patients who underwent distal pancreatectomy for cancer of the pancreatic body and tail. We investigated intrapancreatic cancer spread in these patients histopathologically and analyzed the relationship between 2-cm-margin positivity and other clinicopathological characteristics. RESULTS Two-centimeter-margin positivity was observed in 17 cases. In these, tumors had a tendency to spread toward the pancreatic head along the main pancreatic duct. As a result of statistical analysis, we considered venous invasion (odds ratio [OR], 15.48; 95% confidence interval [CI], 1.61-148.94; P = 0.0177), 2-cm-margin fibrosis (OR, 173.88; 95% CI, 8.96-3375.03; P = 0.0007), and 2-cm-margin hardness (OR, 5.97; 95% CI, 1.07-33.46; P = 0.0420) as being independently related to 2-cm-margin positivity. CONCLUSIONS The results suggest that 2 cm is not a safe length to ensure a negative margin. In the future, preoperative and intraoperative evaluation of the degree of fibrosis of pancreatic parenchyma could lead to cancer-free pancreatic cut-end margins.
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Belyaev O, Munding J, Herzog T, Suelberg D, Tannapfel A, Schmidt WE, Mueller CA, Uhl W. Histomorphological features of the pancreatic remnant as independent risk factors for postoperative pancreatic fistula: a matched-pairs analysis. Pancreatology 2011; 11:516-24. [PMID: 22056514 DOI: 10.1159/000332587] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/01/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Postoperative pancreatic fistula (POPF) is a major complication after resective pancreatic surgery. This study aimed to identify histomorphological features of the pancreatic remnant as independent determinants for the development of POPF. METHODS Twenty-five patients, 3.6% of 696 resections over a period of 5 years, who developed POPF were matched for age, gender, diagnosis, comorbidities, surgeon and procedure with 25 controls without POPF. Pancreatic duct size and index, fibrosis grade, fat content, edema, and signs of chronic and acute inflammation were measured in frozen sections of the resection margin and were then compared. RESULTS The POPF rate was 12.2 and 2.6% after distal pancreatectomy and pancreatoduodenectomy, respectively. The POPF group was characterized by a longer ICU and total postoperative stay, higher rate of reoperations and complications. Their pancreata were softer at palpation (88 vs. 56%). Their pancreatic duct was smaller (2.5 vs. 3.2 mm) and their pancreatic fat content higher (16 vs. 8%). High inter- and intralobular fat content, small duct size, low interlobular fibrosis grade and lack of signs of chronic pancreatitis were predictors of POPF development. A score including these parameters identified high-risk patients with a sensitivity of 92% and a specificity of 84%. CONCLUSION Histomorphological features of the pancreatic remnant play an independent role as risk factors for the development of POPF. A simple histological score based on the frozen sections may already intraoperatively predict the risk of POPF development.
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Affiliation(s)
- Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Bochum, Germany
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The correlation between durometer score and modified Rodnan skin score in systemic sclerosis. Rheumatol Int 2011; 32:2465-70. [PMID: 21769489 DOI: 10.1007/s00296-011-1993-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 07/03/2011] [Indexed: 10/18/2022]
Abstract
The aims of the present study were to determine the correlation between durometer scores with modified Rodnan skin scores (MRSS), scleroderma symptoms, and physical functions. A total of 31 patients with systemic sclerosis (SSc, 16 diffuse and 15 limited type) were enrolled in this study. Skin involvement was measured using a durometer and MRSS. Health assessment questionnaire (HAQ) disability indices, Keitel function test (KTF) scores, grip strengths, and scleroderma-visual analog scale (scleroderma-VAS) scores were measured. The correlations between durometer scores with MRSS, HAQ disability indices, and scleroderma-VAS scores were assessed. Durometer scores correlated well with MRSS at fingers, hands, forearms, upper arms, thighs, and feet, but poorly correlated with MRSS at the chest, abdomen, and lower legs. Total durometer scores correlated well with MRSS (r = 0.537, P = 0.002) and KTF scores (r = 0.608, P < 0.001), but poorly correlated with HAQ disability indices (r = 0.202, P = 0.276), and individual scleroderma-VAS scores. Durometer-measured skin hardnesses were found to correlate well with the MRSS scores of fingers, hands, forearms, upper arms, thighs, and feet. The authors suggest that these skin sites should be included when durometer measurements are made in systemic sclerosis.
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Court LE, Seco J, Lu XQ, Ebe K, Mayo C, Ionascu D, Winey B, Giakoumakis N, Aristophanous M, Berbeco R, Rottman J, Bogdanov M, Schofield D, Lingos T. Use of a realistic breathing lung phantom to evaluate dose delivery errors. Med Phys 2011; 37:5850-7. [PMID: 21158297 DOI: 10.1118/1.3496356] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To compare the effect of respiration-induced motion on delivered dose (the interplay effect) for different treatment techniques under realistic clinical conditions. METHODS A flexible resin tumor model was created using rapid prototyping techniques based on a computed tomography (CT) image of an actual tumor. Twenty micro-MOSFETs were inserted into the tumor model and the tumor model was inserted into an anthropomorphic breathing phantom. Phantom motion was programed using the motion trajectory of an actual patient. A four-dimensional CT image was obtained and several treatment plans were created using different treatment techniques and planning systems: Conformal (Eclipse), step-and-shoot intensity-modulated radiation therapy (IMRT) (Pinnacle), step-and-shoot IMRT (XiO), dynamic IMRT (Eclipse), complex dynamic IMRT (Eclipse), hybrid IMRT [60% conformal, 40% dynamic IMRT (Eclipse)], volume-modulated are therapy (VMAT) [single-arc (Eclipse)], VMAT [double-arc (Eclipse)], and complex VMAT (Eclipse). The complex plans were created by artificially pushing the optimizer to give complex multileaf collimator sequences. Each IMRT field was irradiated five times and each VMAT field was irradiated ten times, with each irradiation starting at a random point in the respiratory cycle. The effect of fractionation was calculated by randomly summing the measured doses. The maximum deviation for each measurement point per fraction and the probability that 95% of the model tumor had dose deviations less than 2% and 5% were calculated as a function of the number of fractions. Tumor control probabilities for each treatment plan were calculated and compared. RESULTS After five fractions, measured dose deviations were less than 2% for more than 95% of measurement points within the tumor model for all plans, except the complex dynamic IMRT, step-and-shoot IMRT (XiO), complex VMAT, and single-arc VMAT plans. Reducing the dose rate of the complex IMRT plans from 600 to 200 MU/min reduced the dose deviations to less than 2%. Dose deviations were less than 5% after five fractions for all plans, except the complex single-arc VMAT plan. CONCLUSIONS Rapid prototyping techniques can be used to create realistic tumor models. For most treatment techniques, the dose deviations averaged out after several fractions. Treatments with unusually complicated multileaf collimator sequences had larger dose deviations. For IMRT treatments, dose deviations can be reduced by reducing the dose rate. For VMAT treatments, using two arcs instead of one is effective for reducing dose deviations.
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Affiliation(s)
- Laurence E Court
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Wellner UF, Kayser G, Lapshyn H, Sick O, Makowiec F, Höppner J, Hopt UT, Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford) 2010; 12:696-702. [PMID: 21083795 PMCID: PMC3003480 DOI: 10.1111/j.1477-2574.2010.00239.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is regarded as the most serious complication of pancreatic surgery. The preoperative risk stratification of patients by simple means is of interest in perioperative clinical management. METHODS Based on prospective data, we performed a risk factor analysis for POPF after pancreatoduodenectomy in 62 patients operated between 2006 and 2008 with special focus on clinical parameters that might serve to predict POPF. A predictive score was developed and validated in an independent second dataset of 279 patients operated between 2001 and 2010. RESULTS Several pre- and intraoperative factors, as well as underlying pathology, showed significant univariate correlation with rate of POPF. Multivariate analysis (binary logistic regression) disclosed soft pancreatic texture (odds ratio [OR] 10.80, 95% confidence interval [CI] 1.80-62.20) and history of weight loss (OR 0.15, 95% CI 0.04-0.66) to be the only independent preoperative clinical factors influencing POPF rate. The subjective assessment of pancreatic hardness by the surgeon correlated highly with objective assessment of pancreatic fibrosis by the pathologist (r = -0.68, P < 0.001, two-tailed Spearman's rank correlation). A simple risk score based on preoperatively available clinical parameters was able to stratify patients correctly into three risk groups and was independently validated. CONCLUSIONS Preoperative stratification of patients regarding risk for POPF by simple clinical parameters is feasible. Pancreatic texture, as evaluated intraoperatively by the surgeon, is the strongest single predictive factor of POPF. The findings of the study may have important implications for perioperative risk assessment and patient care, as well as for the choice of anastomotic techniques.
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Affiliation(s)
| | - Gian Kayser
- Institute of Pathology, University Hospital FreiburgFreiburg, Germany
| | - Hryhoriy Lapshyn
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
| | - Olivia Sick
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
| | - Frank Makowiec
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
| | - Jens Höppner
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
| | - Ulrich Theodor Hopt
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
| | - Tobias Keck
- Department of General and Visceral Surgery, University Hospital FreiburgFreiburg, Germany
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Rottmann J, Aristophanous M, Chen A, Court L, Berbeco R. A multi-region algorithm for markerless beam's-eye view lung tumor tracking. Phys Med Biol 2010; 55:5585-98. [DOI: 10.1088/0031-9155/55/18/021] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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