Perioperative management in distal pancreatectomy: results of a survey in 23 European participating centres of the DISPACT trial and a review of literature

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Abstract

Background

Concomitant treatment in addition to intervention may influence the primary outcome, especially in complex interventions such as surgical trials. Evidence-based standards for perioperative care after distal pancreatectomy, however, have been rarely defined. This study's objective was therefore to identify and analyse the current basis of evidence for perioperative management in distal pancreatectomy.

Methods

A standardised questionnaire was sent to 23 European centres recruiting patients for a randomized controlled trial (RCT) on open distal pancreatectomy that would compare suture versus stapler closure of the pancreatic remnant (DISPACT trial, ISRCTN 18452029). Perioperative strategies (e.g., bowel preparation, pain management, administration of antibiotics, abdominal incision, drainages, nasogastric tubes, somatostatin, mobilisation and feeding regimens) were assessed. Moreover, a systematic literature search in the Medline database was performed and retrieved meta-analyses and RCTs were reviewed.

Results

All 23 centres returned the questionnaire. Consensus for thoracic epidural catheters (TECs), pain treatment and transverse incisions was found, as well as strong consensus for the placement of intra-abdominal drainages and perioperative single-shot antibiotics. Also, there was consensus that bowel preparation, somatostatin application, postoperative nasogastric tubes and intravenous feeding might not be beneficial. The literature search identified 16 meta-analyses and 19 RCTs demonstrating that bowel preparation, somatostatin therapy and nasogastric tubes can be omitted. Early mobilisation, feeding and TECs seem to be beneficial for patients. The value of drainages remains unclear.

Conclusion

Most perioperative standards within the centres participating in the DISPACT trial are in accordance with current available evidence. The need for drainages requires further investigation.

Trial registration

Clinical trial registration : ISRCTN 18452029

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Most cited references 59

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Evidence-based surgical care and the evolution of fast-track surgery.

Henrik Kehlet, Douglas Wilmore (2008)

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. To assess, synthesize, and discuss implementation of "fast-track" recovery programs. Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

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Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators.

T Sohn, Darren Yeo, J L Cameron … (2015)

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

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Hospital volume and late survival after cancer surgery.

John Birkmeyer, Yating Sun, Sandra L Wong … (2007)

Although hospital procedure volume is clearly related to operative mortality with many cancer procedures, its effect on late survival is not well characterized. To examine relationships between hospital volume and late survival after different types of cancer resections. Using the national Surveillance Epidemiology and End Results (SEER)-Medicare linked database (1992-2002), we identified all patients undergoing major resections for lung, esophageal, gastric, pancreatic, colon, and bladder cancer (n = 64,047). Relationships between hospital volume and survival were assessed using Cox proportional hazards models, adjusting for patient characteristics and use of adjuvant radiation and chemotherapy. U.S. Medicare patients residing in SEER regions. 5-year survival. Although there were statistically significant relationships between hospital volume and 5-year survival with all 6 cancer types, the relative importance of volume varied markedly. Absolute differences in 5-year survival probabilities rates between low-volume hospitals (LVHs) and high-volume hospitals (HVHs) ranged from 17% for esophageal cancer resection (17% vs. 34%, respectively) to only 3% for colon cancer resection (45% vs. 48%). Absolute differences in 5-year survival between LVHs and HVHs fell between these ranges for lung (6%), gastric (6%), pancreatic (5%), and bladder cancer (4%). Volume-related differences in late survival could not be attributed to differences in rates of adjuvant therapy. Along with lower operative mortality, HVHs have better late survival rates with selected cancer resections than their lower-volume counterparts. Mechanisms underlying their better outcomes and thus opportunities for improvement remain to be identified.

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Author and article information

Journal

Journal ID (nlm-ta): Trials

Title: Trials

Publisher: BioMed Central

ISSN (Electronic): 1745-6215

Publication date Collection: 2009

Publication date (Electronic): 26 July 2009

Volume: 10

Page: 58

Affiliations

[1 ]Department of General, Visceral and Transplantation Surgery, Ruprecht-Karls-University Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany

[2 ]Study Centre of the German Surgical Society (SDGC), Ruprecht-Karls-University Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany

[3 ]Department of General, Visceral, and Transplantation Surgery, Universitätsmedizin Berlin, Augustenburger Platz 1, Charité Campus Virchow Klinikum, 13353 Berlin, Germany

[4 ]Policlinico Borgo Roma, Universita di Verona, Piazzale La Scuro 10, 37134 Verona, Italy

[5 ]Department of General Surgery, Technische Universität München, Ismaningerstrasse 22, Munich 81675, Germany

[6 ]Department of General, Visceral, Vascular and Thoracic Surgery, Universitätsmedizin Berlin, Charitéplatz 1, Charité Campus Mitte, 10117 Berlin, Germany

Article

Publisher ID: 1745-6215-10-58

DOI: 10.1186/1745-6215-10-58

PMC ID: 2726965

PubMed ID: 19630998

SO-VID: 7b9ca36b-f55a-4b9a-af03-c858284a8d3c

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Perioperative management in distal pancreatectomy: results of a survey in 23 European participating centres of the DISPACT trial and a review of literature

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Abstract

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Trial registration

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Herbal Medicines Journal (Herb Med J)

Most cited references 59

Evidence-based surgical care and the evolution of fast-track surgery.

Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators.

Hospital volume and late survival after cancer surgery.

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