| 1. |
- Bratlie, Svein-Olav, et al.
(författare)
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Resectable, borderline, and locally advanced pancreatic cancer-"the good, the bad, and the ugly" candidates for surgery?
- 2021
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Ingår i: Journal of Gastrointestinal Oncology. - : AME Publishing Company. - 2078-6891 .- 2219-679X. ; 12:5, s. 2450-2460
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Tidskriftsartikel (refereegranskat)abstract
- The possibility of surgical resection strongly overrules medical oncologic treatment and is the only modality, causa sine qua non, long-term survival can be achieved in patients with pancreatic cancer. For this reason, the clinical classification of local resectability, subdividing tumors into resectable, borderline resectable, and locally advanced cancer, that is very technical in nature, is the one most widely used and accepted. As multimodality treatment with potent agents, particularly in the neoadjuvant setting, seems to be stepping forward as the new standard of treatment of pancreatic cancer, the established technical surgical landmarks tend to get challenged. This review aims to highlight the grey zones in the current classifications for local tumor involvement with respect to the observed patient outcome in the current multimodality treatment era. It summarizes the latest reported series on the outcome of resected primary resectable, borderline and locally advanced pancreatic cancer, and particularly vascular resections during pancreatectomy, in the background of different types of neoadjuvant therapy. It also hints what the new horizons of cancer biology tend to reveal whenever the technical hinders start being pushed aside. The current calls for the necessity of re-classification of the clinical categories of pancreatic cancer, from technically oriented to biology-focused individualized approach, are being elucidated.
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| 2. |
- Casselbrant, Anna, 1970, et al.
(författare)
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Actions by angiotensin II on esophageal contractility in humans
- 2007
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Ingår i: Gastroenterology. - : Elsevier BV. - 0016-5085. ; 132:1, s. 249-60
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND & AIMS: Angiotensin II is a potent activator of smooth muscles but has not been much investigated with regard to gastrointestinal motor activity. This study explores expression of the renin-angiotensin system (RAS) in human esophageal musculature and actions by Angiotensin II both in vitro and in vivo. METHODS: Muscular specimens of esophageal body and lower esophageal sphincter were obtained from patients undergoing resection as a result of mucosal neoplasm. Healthy volunteers participated in functional examinations of esophageal motility assessed by high-resolution manometry and multiple transmucosal potential-difference measurements. RESULTS: Gene transcripts of key components of RAS were found in the esophageal musculature. Immunohistochemistry revealed a distinct staining for Angiotensin II type 1 (AT(1)) receptors in the muscular bundles and blood-vessel walls, whereas Angiotensin II type 2 receptors were confined to blood vessels only. Angiotensin II caused concentration-dependent contractions in vitro, which were inhibited by the AT(1) receptor antagonist losartan but not by the Angiotensin II type 2 receptor antagonist PD123319. Administration of the AT(1) receptor antagonist candesartan reduced the amplitude of swallow-induced peristaltic contractions and both the length and pressure amplitude of baseline high-pressure zone at the esophagogastric junction. Neither swallow-induced axial movements, nor the contraction after transient lower esophageal sphincter relaxations, were influenced by candesartan pretreatment. CONCLUSIONS: The study demonstrates a local RAS in the musculature of the distal esophagus and that Angiotensin II is a potent stimulator of esophageal contractions via the AT(1) receptor. The results suggest that Angiotensin II participates in the physiological control of the human esophageal motor activity.
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| 3. |
- Fagevik Olsén, Monika, 1964, et al.
(författare)
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Development of and adherence to an ERAS® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study
- 2023
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Ingår i: Scandinavian Journal of Surgery. - 1457-4969 .- 1799-7267. ; 112:4, s. 235-245
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Tidskriftsartikel (refereegranskat)abstract
- Background and objective: There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery. Methods: Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients’ hospital records. Patients’ adherence to advice given pre-operatively was followed up using a study-specific questionnaire. Results: The patients reported high adherence to remembered advice given. The health care professionals’ adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups. Conclusion: The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.
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| 4. |
- Wennerblom, Johanna, 1969, et al.
(författare)
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Lymph node 8a as a prognostic marker for poorer prognosis in pancreatic and periampullary carcinoma.
- 2018
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Ingår i: Scandinavian journal of gastroenterology. - : Informa UK Limited. - 1502-7708 .- 0036-5521. ; 53:2, s. 225-230
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Tidskriftsartikel (refereegranskat)abstract
- An investigation of patients with pancreatic carcinoma aims to identify those who will benefit from surgery. Physical examination, radiology and laboratory findings are helpful. Most prognostic markers, such as lymph node status, micro metastasis and tumour differentiation, are not preoperatively accessible. Metastatic disease in lymph node 8a (Ln8a) in patients operated for pancreatic carcinoma has been reported to be a predictor of shorter overall survival (OS). This lymph node can be assessed preoperatively through resection (possibly even with laparoscopy) and subsequent histopathology. The value of the procedure is disputed. The aim of this study is to investigate whether metastatic disease in Ln8a is a predictor of decreased OS.In patients with suspected pancreatic or periampullary carcinoma, who were operated with pancreatoduodenectomy (PD), Ln8a was separately resected and analysed with standard and immuno-histochemical methods. Patients with or without metastasis in Ln8a were compared regarding OS.Between 2008 and 2011, 122 consecutive patients were eligible and 87 were resected and had LN8a analysed separately. Sixteen patients were Ln8a+and 71 were Ln8a-. Patients with Ln8a+had a significantly reduced median OS as compared to patients with Ln8a- (0.74 (95% CI 0.26-1.26) versus 5.91 years (95% CI 2.91-), p<.001).Ln8a+was associated with a marked reduction of OS, indicating a possible role in the future preoperative workup in patients with a suspicion of pancreatic cancer.
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| 5. |
- Wennerblom, Johanna, 1969, et al.
(författare)
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Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial
- 2021
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Ingår i: The British journal of surgery. - : Oxford University Press (OUP). - 1365-2168 .- 0007-1323. ; 108:3, s. 265-270
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line. METHODS: An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay. RESULTS: Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P=0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P=0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P=0.541). CONCLUSION: Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov). © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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| 6. |
- Wennerblom, Johanna, 1969
(författare)
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Surgical methods in treating pancreatic tumours
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In patients with pancreatic cancer 15-20% are resectable at the time of diagnosis. Still another 8-20% are found to be unresectable at laparotomy. The optimal intraoperative strategy for this group is not known. Some patients experience early recurrence of the cancer indicating undetected advanced disease at the time of surgery. We need tools to detect these patients, who do not benefit from surgery. Pancreatic surgery is still associated with a high burden of complications, postoperative pancreatic fistula (POPF) being the potentially most harmful. The overall aim of this thesis project was to investigate whether modification of existing surgical techniques and preoperative routines can improve postoperative outcome in patients with pancreatic tumours. Methods: Paper I was a retrospective study comparing postoperative outcome for patients diagnosed with unresectable periampullary cancer at laparotomy and treated either with endoscopically placed stents on demand or prophylactic double bypass surgery. Paper II was a prospective study where patients treated with PD for suspected periampullary cancer had lymph node (Ln) 8a separately analysed. Tumour status of the lymph node was compared regarding overall survival (OS). Paper III was an RCT randomizing patients planned for DP to stapler division of the pancreas with or without stapler reinforcement, looking at POPF frequency postoperatively. Paper IV is a registry-based study that retrieved data from the Swedish National Pancreatic and Periampullary Cancer Registry to compare two pancreatic reconstructions after PD, pancreatogastrostomy (PG) and pancreatojejunostomy (PJ), regarding POPF development. Results: Paper I – There were more complications and longer hospital stay in the surgery group compared to the group treated with stent on demand. In addition a prophylactic gastroenteric anastomosis did not prevent future gastric outlet obstruction. Paper II - Tumour growth in Ln8a is associated with a substantial reduction of OS. Paper III – No differences in POPF between the study groups were observed. Paper IV - The PJ group had significantly more clinically relevant POPF and more severe complications than the PG group. Conclusions: Patients with unresectable periampullary malignancies can safely be managed with endoscopic drainage on demand and with lower morbidity and shorter hospital stay than with surgical prophylactic bypass. Tumour involvement of Ln8a is associated with short OS. Reinforcement of the stapler line in DP does not reduce POPF frequency. PG might to be a safer pancreatic reconstruction than PJ due to less risk of developing clinically relevant POPF.
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| 7. |
- Williamsson, Caroline, et al.
(författare)
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A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer.
- 2016
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Ingår i: HPB : the official journal of the International Hepato Pancreato Biliary Association. - : Elsevier BV. - 1477-2574 .- 1365-182X. ; 18:1, s. 107-12
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Tidskriftsartikel (refereegranskat)abstract
- A patient with unresectable periampullary malignancy found at laparotomy has traditionallyreceived a prophylactic double bypass (biliary and duodenal), associated with considerable morbidity. With modern endoscopic treatments, surgical bypass has become questionable. This study aims to compare the two strategies. Sahlgrenska University Hospital (SU) performs a double bypass (DoB) routinely, and Skåne University Hospital Lund (SUL) secures biliary drainage endoscopically and treats only symptomatic duodenal obstruction (Wait and See, WaS).
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| 8. |
- Williamsson, C., et al.
(författare)
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Predictive Factors for Postoperative Pancreatic Fistula-A Swedish Nationwide Register-Based Study
- 2020
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 44, s. 4207-4213
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Tidskriftsartikel (refereegranskat)abstract
- Background A serious complication after pancreatoduodenectomy (PD) is postoperative pancreatic fistula (POPF). The aim of this study was to analyse the incidence and predictive factors for POPF by using a large nationwide cohort. Methods Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients undergoing a PD from 2010 until 30th June 2018 were collected. The material was analysed in two groups, no POPF and clinically relevant (grade B and C) POPF. Results A total of 2503 patients underwent PD, of which 245 (10%) developed POPF. Patients with POPF had significantly more overall complications (Clavien Dindo >= 3a, 75% vs. 21%,p < 0.001) and longer hospital stay (median 23 [16-35] vs. 11 [8-15],p < 0.001) than patients without POPF. The risk of POPF was higher with increased BMI (OR 1.08,p < 0.001). Preoperative presence of diabetes (OR 0.52,p = 0.012) and preoperative biliary drainage (OR 0.34,p < 0.001) reduced the risk of POPF. Reconstruction with pancreaticojejunostomy caused a more than two folded increase in POPF compared with pancreaticogastrostomy (OR 2.41,p < 0.001). Weight gain >= 2 kg on postoperative day 1 was also a risk factor (OR 1.76,p < 0.001). Conclusion A high BMI, a pancreaticojejunostomy and postoperative weight gain were risk factors for developing POPF. Diabetes or preoperative biliary drainage was protective.
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| 9. |
- Zdanowski, A. H., et al.
(författare)
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Predictive Factors for Delayed Gastric Emptying After Pancreatoduodenectomy: A Swedish National Registry-Based Study
- 2023
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Ingår i: WORLD JOURNAL OF SURGERY. - 0364-2313. ; 47, s. 3289-3297
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Tidskriftsartikel (refereegranskat)abstract
- Background Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy (PD). DGE causes prolonged hospital stay and a decrease in quality of life. This study analyzes predictive factors for development of DGE after PD, also in the absence of surgical complications.Method Data from the Swedish National Pancreatic Cancer Registry for patients undergoing standard and pylorus preserving open PD from January 2010 until June 30, 2018, were collected. Data were analyzed in two groups, no DGE and DGE. A subgroup of patients with DGE but without surgical complications was compared to patients without DGE or any other surgical complication.Results In total, 2503 patients were included, of which 470 (19%) had DGE. In the DGE group, 238 had other coexisting surgical complications and 232 had not. Postoperative pancreatic fistula (OR = 4.22, p < 0.001), surgical infection (OR = 1.44, p = 0.013), heart disease (OR = 1.32, p = 0.023) and medical complications (OR = 1.35, p = 0.025) increased the risk for DGE. A standard PD compared with pylorus preserving resection (OR = 1.69, p = 0.001) and a reconstruction with a pancreaticojejunostomy compared with a pancreaticogastrostomy (OR = 1.83, p < 0.001) increased the risk. For patients without surgical complications, a standard PD and reconstruction with pancreaticojejunostomy still increased the risk for DGE.Conclusion DGE is more common after standard PD compared to pylorus preserving PD and after reconstruction with PJ compared to PG in this national cohort, both in the presence of other surgical complications as well as in the absence of other complications.
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