Challenges and Opportunities in Pancreatic Surgery
Abstract
Background: In the current literature different diagnosis and treatment strategies for chyle leak after pancreatic surgery are described. In 2017, the International Study Group for Pancreatic Surgery defined a consensus-based definition for diagnosis. However, consensus on the optimal treatment strategy is lacking.
Aim: The aim of this multicenter study is to investigate the current treatment and diagnosis of chyle leak after pancreatic surgery in clinical practice in the Netherlands to gain insight into practical applications of chyle leak.
Methods: A nationwide survey about the diagnosis and treatment of chyle leak was sent to specialized dieticians and pancreatic surgeons from all 16 pancreatic centers collaborating in the Dutch Pancreatic Cancer Group. Data was quantitative processed according to thematic content analysis and by using descriptive analysis.
Results: In total, 16 dieticians from 16 centers and 20 surgeons from 12 centers completed the questionnaire. Analysis showed that the International Study Group for Pancreatic Surgery-definition for chyle leak was used in clinical practice by 31% (n=11) of the respondents. The results show also large nationwide variation in treatment of chyle leak after pancreatic surgery, as well between as within centers. The most common treatment was a step-up approach of nutritional therapies (44% (n=16)), which starts with an enteral fat restricted diet enriched with medium chain fatty acids followed by total parenteral nutrition.
Conclusion This study shows that the current diagnosis and treatment strategies for chyle leak after pancreatic surgery in clinical practice on a nationwide scale are different. More comparable studies are needed to define the optimal treatment strategy for chyle leak. There is need for an international multidisciplinary (sub)working group to reach consensus on the treatment strategy of chyle leak and to discuss implementation strategies for clinical practice.
Charlotte Justina Maria van den Bosch
Department of Nutrition and Dietetics, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
L. Blonk
Department of Nutrition and Dietetics, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands ; Department of Surgery, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
J. Straatman
Department of Surgery, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
G. Kazemier
Department of Surgery, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
N. J. Wierdsma
Department of Nutrition and Dietetics, Amsterdam University Medical Centers, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, de Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
Abstract
Background: Treatment with pancreatic enzymes is necessary to improve nutrient digestion and to prevent malabsorption in patients with exocrine pancreatic insufficiency (EPI) after pancreatoduodenectomy. Aim of this study was to identify the optimal dosage of pancreatic enzymes in patients with EPI after pancreatoduodenectomy based on studies available and to evaluate if patients in our cohort are treated adequately.
Methods: A systematic review of literature was performed to identify all randomized controlled trials reporting on the effect of treatment with pancreatic enzymes on nutritional parameters after pancreatoduodenectomy. Alongside a prospective observational study was performed, where the administered dosage of pancreatic enzymes was evaluated by a questionnaire in patients after pancreatoduodenectomy with EPI (defined as fat absorption < 85 %), and was compared to their dietary fat intake. Endpoints of this study were (1) the percentage of patients that received an adequate dosage based on the results of the systematic literature study, (2) the ratio between reported dose lipase (PhEur units) and fat intake (g), and reported dose of protease (PhEur units) and protein intake (g).
Results: The systematic review revealed three randomized controlled trials, their results indicate that an effective dosage of pancreatic enzymes to treat EPI following pancreatoduodenectomy should consists of at least 40000 PhEur units lipase per main meal. Twenty-nine patients with EPI after pancreatoduodenectomy were included in the prospective study. The recommended dosage (minimum 40000 PhEur units of lipase) was administered in 52% of the patients. The lowest ratio of the PhEur units of lipase per gram dietary fat intake was observed during dinner (2521 ±1770 units/gram fat) and the highest ratio was observed during breakfast (4441 ± 6936 units/gram fat).
Conclusion: According to the cut-off of minimal 40000 PhEur units of lipase per main meal, only half of the patients are using the minimum dosage of pancreatic enzymes. The variability between the ratios of the reported dose of lipase (PhEur units) and fat intake (g) fat intake per main meals is large and prescribing pancreatic enzymes adjusted to fat intake (as ratio’s) seems more appropriate.
Frank Gansauge
Center for oncologic, endocrine and minimal-invasive surgery, Silcherstr. 36, 89231, Neu-Ulm, Germany; Shanxi University, Taiyuan, China; LDG – laboratories Dr. Gansauge – GmbH, Sedanstr. 14, 89077 Ulm, Germany
Bertram Poch
Center for oncologic, endocrine and minimal-invasive surgery, Silcherstr. 36, 89231, Neu-Ulm, Germany; Shanxi University, Taiyuan, China
Abstract
Purpose: Despite improved diagnostic and therapeutic facilities median survival in pancreatic cancer is still unsatisfactory Here we retrospectively analyzed the outcome of immunotherapy in the additional palliative treatment of pancreatic cancer with long antigen exposition dendritic cell therapy (LANEX-DC®) in 200 patients who were treated at our institution (intent-to- treat-analysis).
Patients: Data were available of 200 patients.The mean interval between first diagnosis and start of treatment was 1,5 months. 148 patients received one cycle of dendritic cell therapy, 52 patients received 2 or more cycles of dendritic cell therapy.
Results: Therapy was well tolerated and no serious side effects were observed. The survival rate after 6 months was 70,9 % and afters 9 month 51,0%. The median survival time according to Kaplan- Meier regression analysis was 9,1 months. Median survival was significantly higher in the group of patients who started immunotherapy within 1,5 months following diagnosis (7,9 months versus11,8 months, p=0,009). Patients with two or more cycles of dendritic cell therapy lived significantly longer than patients with just one cycle (17,5 months versus 7,4 months, p=0,001). Interestingly younger patients < 65 years of age lived significantly longer as patients >= 65 years of age (p = 0,004).
Conclusion: We were able to demonstrate in a large retrospective cohort analysis that additional treatment with dendritic cells is highly effective and extends the median survival times up to 17,5 months in case of regular repetition of dendritic cell therapy. Furthermore, we were able to demonstrate that median survival can be increased by early beginning dendritic cell therapy.
Abstract
In the Anglophone Caribbean, laparoscopic surgery for pancreatic malignancies has been reported at low volumes and there has been no report of radical antegrade modular pancreatico-splenectomy (RAMPS), which is increasingly replacing conventional distal pancreatectomy. Performing RAMPS with laparoscopic instruments is technically difficult, but it is feasible. We report our experience performing minimally invasive RAMPS using the FreeHand® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, UK) in Trinidad & Tobago.
Meghan Cook, Meghan Ferguson, Alma Garcia, Katie Konieczny, Kevin Bumanglag, Thi Tran & Robert B. Campbell
Abstract
Neuroblastoma is a solid malignancy observed in pediatric patients developing when neuroblasts are unable to mature, leading to unregulated proliferation and tumor formation. Neuroblastoma is heterogeneous and aggressive in nature, leading to high treatment failure, morbidity, and mortality rates. Lewis family glycans, as part of the Core 2 O-glycans, play a key role in neuroblastoma malignant cell behavior in MYCN-amplified cell lines. Current treatment approaches for neuroblastoma include chemotherapy, surgery, and radiation. These approaches are faced with physiological and cellular barriers, including the less understood role of glycosylation in development and treatment. Studies have confirmed that the inhibition of mucin glycosylation has improved effectiveness of cytotoxic drug agents employed against solid malignancies such as with pancreatic cancer, yet little research is available regarding the influence of glycosylated proteins for other diseases. This article explores genetic defects associated with neuroblastoma such MYCN gene amplification at the time of diagnosis, as well as clinical approaches and therapeutic challenges encountered during treatment. Additionally, the article reviews experimental and clinical evidence in support of the influence of glycosylation in neuroblastoma development, and possible unfavorable impact of glycosylation on drug therapy.
