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Rocha F.G.,Virginia Mason Medical Center | Hashimoto Y.,Hiroshima University | William Traverso L.,Center for Pancreatic Disease | Dorer R.,Virginia Mason Medical Center | And 3 more authors.
Annals of Surgery

Objective: To report the long-term impact of adjuvant interferon-based chemoradiation therapy (IFN-CRT) after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Background: In 2003, we reported an actuarial 5-year overall survival (OS) of 55% (22 months median follow-up) using adjuvant IFN-CRT after PD. As the original cohort is now10 years distant fromPD,we sought to examine their actual survival, describe patterns of recurrence, and determine prognostic factors. Methods: From 1995 to 2002, 43 patients underwent PD for PDAC and received adjuvant IFN-CRT consisting of external-beam irradiation, continuous 5-fluorouracil infusion, weekly intravenous bolus cisplatin, and subcutaneous interferon-a. Survival was calculated by the method of Kaplan and Meier, and prognostic factors were compared using a log-rank test and a Cox proportional hazards model. Results: With all patients at least 10 years from PD, the 5-year actual survival was 42% and 10-year actual survival was 28% with median OS of 42 months (95% confidence interval: 22-110 months). Nine patients survived beyond 10 years with 7 currently alive without evidence of disease. Initial recurrence included 4 local, 17 distant, and 4 combined sites at a median of 25 months. IFN-CRT was interrupted in 70% of patients because of grade 3 or 4 toxicity, whereas 42% of patients required hospitalization. Adverse prognostic factors included lymph node ratio of 50% or more, Eastern Cooperative Oncology Group performance status of 1 or higher, and IFN-CRT treatment interruption. Conclusions: Adjuvant IFN-CRT after PD can provide long-term survival in resected PDAC. Further studies should focus on patient and tumor factors to maximize benefit and minimize toxicity. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Source

Moriya T.,Virginia Mason Medical Center | Hashimoto Y.,Virginia Mason Medical Center | Traverso L.W.,Virginia Mason Medical Center | Traverso L.W.,Center for Pancreatic Disease
Journal of Gastrointestinal Surgery

Introduction: Using Kaplan-Meier curves, a 2006 study illustrated a shorter time interval between development of symptoms and detection of malignant IPMN in the main pancreatic duct versus a side-branch duct location. Of 93 cases, only 62 were confirmed histologically. To support these interesting findings, we examined a larger cohort of cases where the diagnosis was confirmed histologically and asked if symptoms by themselves, as well as main duct location, were associated with malignant detection. Methods: Between 1989 and 2009, 210 IPMN cases meeting international criteria were resected and histologically examined. Actuarial rates of malignant detection over time were calculated from the first clinical symptom to malignant detection (resection). These rates of malignant detection over time were compared for main vs. side-branch duct location and symptomatic vs. asymptomatic cases. Results: The most common indications for resection were symptoms (88%) and main pancreatic duct location (65%). The actuarial malignant detection rates were significantly shorter for main duct location and also for symptomatic cases, regardless of duct location. Conclusions: Presence of symptoms followed by main pancreatic duct location had a significantly shorter elapsed time to malignant detection. The visual depiction of these actuarial rates highlights the importance of the clinical history. To determine malignant risk, the primary determinants for resection were either symptoms or main duct location (but not cyst size), confirming the 2006 study with a larger cohort of histologically confirmed cases. © 2011 The Society for Surgery of the Alimentary Tract. Source

Hashimoto Y.,Virginia Mason Medical Center | Traverso L.W.,Virginia Mason Medical Center | Traverso L.W.,Center for Pancreatic Disease
Journal of Gastrointestinal Surgery

Hypothesis The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump. Goal The aim of this study was to identify controllable risk factors for POPF. Methods In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public webbased tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C). Results Mortality was zero. ISGPS gradings were: no POPF 53%, grade A032%, B013.9%, and C00.9%. The clinicalrelevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung's duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors-intraoperative blood loss >1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung's duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n0177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage. Conclusions Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia. © 2012 The Society for Surgery of the Alimentary Tract. Source

Gluck M.,Virginia Mason Medical Center | Ross A.,Virginia Mason Medical Center | Irani S.,Virginia Mason Medical Center | Lin O.,Virginia Mason Medical Center | And 8 more authors.
Journal of Gastrointestinal Surgery

Background: Symptomatic walled-off pancreatic necrosis (WOPN) treated with dual modality endoscopic and percutaneous drainage (DMD) has been shown to decrease length of hospitalization (LOH) and use of radiological resources in comparison to standard percutaneous drainage (SPD). Aim: The aim of this study is to demonstrate that as the cohort of DMD and SPD patients expand, the original conclusions are durable. Methods: The database of patients receiving treatment for WOPN between January 2006 and April 2011 was analyzed retrospectively. Patients: One hundred two patients with symptomatic WOPN who had no previous drainage procedures were evaluated: 49 with DMD and 46 with SPD; 7 were excluded due to a salvage procedure. Results: Patient characteristics including age, sex, etiology of pancreatitis, and severity of disease based on computed tomographic severity index were indistinguishable between the two cohorts. The DMD cohort had shorter LOH, time until removal of percutaneous drains, fewer CT scans, drain studies, and endoscopic retrograde cholangiopancreatography (ERCPs; p < 0.05 for all). There were 12 identifiable complications during DMD, which were successfully treated without the need for surgery. The 30-day mortality in DMD was 4% (one multi-system organ failure and one out of the hospital with congestive heart failure). Three patients receiving SPD had surgery, and three (7%) died in the hospital. Conclusion: DMD for symptomatic WOPN reduces LOH, radiological procedures, and number of ERCPs compared to SPD. © 2011 The Society for Surgery of the Alimentary Tract. Source

Moriya T.,Virginia Mason Medical Center | Traverso L.W.,Virginia Mason Medical Center | Traverso L.W.,Center for Pancreatic Disease
Archives of Surgery

Objective: To determine the occurrence of new disease in the pancreatic remnant after resection for intraductal papillary mucinous neoplasms. Design: A longitudinal level II cohort study. Setting: Virginia Mason Medical Center, Seattle, Washington. Patients: The primary cohort was a "resection cohort"of 203 patients who underwent partial pancreatic resection for an intraductal papillary mucinous neoplasm. Main Outcome Measures: The occurrence rate of lesions in the pancreatic remnant after resection for an intraductal papillary mucinous neoplasm, determined by use of an annual computed tomographic scan of the pancreas. Results: New lesions were observed in the remnant of 17 of the 203 patients (8%) after a median follow-up of 40 months and a median interval of 38 months from the initial resection. Only 1 of these 17 patients with new lesions had a surgical margin that was positive for an adenoma at the time of resection. Comparing the 17 patients with new lesions with the 186 patients without new lesions, we found no difference in age, sex, procedure type, location in ductal system, original histology, or original margin status. In the new lesion group, no treatment was used for 12 patients who had side-branch disease detected by imaging (6% of all patients). Surgical treatment was used for 5 patients (2% of all patients): 2 with adenomas, 1 with a carcinoma in situ, and 2 with an invasive ductal carcinoma (1 with liver metastases). Conclusions: We found that, following a partial pancreatic resection for an intraductal papillary mucinous neoplasm and a 40-month follow-up with an annual computed tomographic scan of the pancreas, 17 of 203 patients (8%) developed a new intraductal papillary mucinous neoplastic lesion in the pancreatic remnant. As follow-up time increases, we suspect that new lesions will constantly appear regardless of whether the surgical margin was negative at initial resection. Source

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