Improving outcomes of minimally invasive pancreas surgery and ampullary cancer

Ampullary adenocarcinoma is a rare tumor that arises from the ampulla of Vater; the confluence of the common bile duct and the pancreatic duct. It represent a heterogeneous group with considerable morphological heterogeneity and therefore, a broad range of survival rates. The only potential curative treatment is surgical resection through a pancreatoduodenectomy, a major procedure with high morbidity- and mortality rates. The role of adjuvant chemotherapy in ampullary adenocarcinoma is unclear. Given the rarity of ampullary adenocarcinomas, no single randomized clinical trial in adjuvant treatment has focused specifically on ampullary adenocarcinoma. The research in this thesis aims to improve the surgical aspect of the treatment, through minimally invasive pancreas surgery, with the focus on implementation and safety. Another pillar of this thesis is improving the prediction of survival after resection of ampullary adenocarcinomas by defining predictors of survival and recurrence as well as developing a prediction model to anticipate 3- and 5-year survival of individual patients. Lastly, the role of adjuvant chemotherapy in ampullary adenocarcinoma is investigated

Improving outcomes of minimally invasive pancreas surgery and ampullary cancer

Ampullary adenocarcinoma is a rare tumor that arises from the ampulla of Vater; the confluence of the common bile duct and the pancreatic duct. It represent a heterogeneous group with considerable morphological heterogeneity and therefore, a broad range of survival rates. The only potential curative treatment is surgical resection through a pancreatoduodenectomy, a major procedure with high morbidity- and mortality rates. The role of adjuvant chemotherapy in ampullary adenocarcinoma is unclear. Given the rarity of ampullary adenocarcinomas, no single randomized clinical trial in adjuvant treatment has focused specifically on ampullary adenocarcinoma. The research in this thesis aims to improve the surgical aspect of the treatment, through minimally invasive pancreas surgery, with the focus on implementation and safety. Another pillar of this thesis is improving the prediction of survival after resection of ampullary adenocarcinomas by defining predictors of survival and recurrence as well as developing a prediction model to anticipate 3- and 5-year survival of individual patients. Lastly, the role of adjuvant chemotherapy in ampullary adenocarcinoma is investigated

Gemcitabine-based adjuvant chemotherapy in subtypes of ampullary adenocarcinoma: international propensity score-matched cohort study

BACKGROUND: Whether patients who undergo resection of ampullary adenocarcinoma have a survival benefit from adjuvant chemotherapy is currently unknown. The aim of this study was to compare survival between patients with and without adjuvant chemotherapy after resection of ampullary adenocarcinoma in a propensity score-matched analysis.METHODS: An international multicentre cohort study was conducted, including patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma between 2006 and 2017, in 13 centres in six countries. Propensity scores were used to match patients who received adjuvant chemotherapy with those who did not, in the entire cohort and in two subgroups (pancreatobiliary/mixed and intestinal subtypes). Survival was assessed using the Kaplan-Meier method and Cox regression analyses.RESULTS: Overall, 1163 patients underwent pancreatoduodenectomy for ampullary adenocarcinoma. After excluding 187 patients, median survival in the remaining 976 patients was 67 (95 per cent c.i. 56 to 78) months. A total of 520 patients (53·3 per cent) received adjuvant chemotherapy. In a propensity score-matched cohort (194 patients in each group), survival was better among patients who received adjuvant chemotherapy than in those who did not (median survival not reached versus 60 months respectively; P = 0·051). A survival benefit was seen in patients with the pancreatobiliary/mixed subtype; median survival was not reached in patients receiving adjuvant chemotherapy and 32 months in the group without chemotherapy (P = 0·020). Patients with the intestinal subtype did not show any survival benefit from adjuvant chemotherapy.CONCLUSION: Patients with resected ampullary adenocarcinoma may benefit from gemcitabine-based adjuvant chemotherapy, but this effect may be reserved for those with the pancreatobiliary and/or mixed subtype.</p

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery