Study Of Total Pancreatectomy In The Surgical Treatment Of Pancreatic Diseases

Objective:By analyzing the Surveillance,Epidemiology,and End Results(SEER)database,to compare the long-term prognosis of pancreatic ductal adenocarcinoma(PDAC)undergoing total pancreatectomy(TP)versus pancreaticoduodenectomy(PD),and identify independent prognostic factors of TP for PDAC,then formulate a nomogram to predict overall survival(OS)for PDAC individuals following TP,which can provide a reference for clinical prediction of long-term survival of patients with PDAC following TP.Materials and methods:Clinical and pathological data of PDAC patients who underwent TP and PD from 2004 to 2015 were collected from the SEER database.Kaplan-Meier method and log-rank test were used to compare OS and cancer-specific survival(CSS)of the two groups.A propensity score matching(PSM)was applied to balance the confounding due to baseline differences between groups,and the caliper value was set to 0.01.OS and CSS of the two groups were compared both before and after PSM,respectively.X-tile software was used to determine the optimal cut-off values for continuous variables.Univariate and multivariate Cox regression were applied to identify the independent factors affecting OS in the TP group to construct the nomogram.The accuracy of the nomogram was measured according to the concordance index(C-index)and calibration plots.Decision curve analysis(DCA)was performed to evaluate the clinical utility of the model,and was compared with the widely-used American Joint Committee on Cancer(AJCC)tumor-node-metastasis(TNM)staging system.X-tile software was used to determine the optimal cut-off value of the nomogram for risk stratification,which divided TP patients into low risk,intermediate risk and high risk groups.Kaplan-Meier method and log-rank test were used to evaluate OS differences among low risk,intermediate risk and high risk groups.Results:A total of 1248 patients were included in the TP group and 5619 patients in the PD group after screening.After a 1:1 PSM,there were 1248 cases in the TP group and 1248 cases in the PD group.There were no significant differences in OS and CSS between TP and PD groups neither before nor after PSM(P>0.05).Univariate Cox regression analysis showed that age,tumor size,tumor differentiation,AJCC T stage,N stage,radiotherapy,chemotherapy,and lymph node ratio(LNR)were correlated with OS of patients in the TP group.Multivariate Cox regression analysis showed that age,tumor differentiation,T stage,radiotherapy,chemotherapy and LNR were independent prognostic indicators affecting OS in TP group,which were selected to construct the nomogram.The C-index of the nomogram model was 0.67 in the training set and 0.69 in the validation set,while C-index of the TNM staging system was 0.59 in the training set and 0.60 in the validation set.The calibration curves showed good uniformity between the nomogram prediction and actual observation.DCA curves indicated that the nomogram had a decent net benefit,which showed more preferable clinical practice than the TNM staging system.The risk stratification of the TP group was divided into low risk group(total score<123),intermediate risk group(total score 123-217)and high risk group(total score>217).There were significant differences in OS among the three groups(P<0.05),which could distinguish the survival risk of individuals following TP.Conclusions:(1)For PD AC patients,there were no significant differences in overall survival and cancer-specific survival between total pancreatectomy and pancreaticoduodenectomy;(2)Age,tumor differentiation,T stage,radiotherapy,chemotherapy and LNR were independent prognostic indicators affecting OS of PDAC patients treated with TP.(3)The nomogram can well predict the prognosis of PD AC patients treated with TP,which demonstrates good discrimination and calibration,and may have better prediction efficiency and clinical practical value than the TNM staging system.Objective:To explore and evaluate the feasibility of total pancreatectomy in the surgical treatment of pancreatic diseases and in elderly patients by analyzing the perioperative outcomes,long-term prognosis and the effects on patients’ postoperative pancreatic endoexocrine functions and quality of life of total pancreatectomy for pancreatic diseases.Materials and methods:The clinical and pathological data of 51 patients who underwent pancreatectomy in the Department of Hepatobiliary and Pancreatic Surgery of Beijing Hospital from January 2017 to January 2021 were retrospectively analyzed.Regular follow-ups were performed to acquire the survival information of the patients.Relevant information was collected from the still living patients with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30(EORTC QLQ-C30,v3.0,Chinese version),the Problem Areas in Diabetes Questionnaire(PAID20,Chinese version),the Diabetes Treatment Satisfaction Questionnaire,Status(DTSQs,Chinese version)and self-designed questionnaires(including blood glucose level,daily insulin dosage,daily pancreatic enzyme dose,stool condition,weight change,etc.)to obtain the patients’ postoperative pancreatic endo-exocrine replacement therapy and quality of life.Comparative analysis was performed on the young group(<65 years old)and the old group(≥65 years old).Results:There were 34 cases of pancreatic ductal adenocarcinoma(PDAC),17 cases of other pathological types,including other types of pancreatic adenocarcinoma,malignant intraductal papillary mucinous neoplasm(IPMN),metastatic carcinoma,main pancreatic duct type IPMN,chronic pancreatitis,etc.;21 patients in the young group and 30 patients in the old group;4 patients lost to follow-up,19 patients were still alive while 28 patients had already died.Median operation time was 390 min.Median intraoperative blood loss was 600 ml.Forty-two patients(82.4%)had an intraoperative blood transfusion,and the median volume was 600 ml.Portal vein/superior mesenteric vein resection and reconstruction were operated in 10 patients(19.6%).Median postoperative hospital stay was 19 days.The postoperative morbidity and mortality rates were 47.1%and 3.9%,respectively.Complications included delayed gastric emptying,bilioenteric anastomotic fistula,abdominal infection,lymphatic leakage,etc.,most of which were minor complications.The overall survival rates for the whole patients were 70.7%and 37.4%at 1 and 3 years,respectively.For patients with malignant diseases,the overall survival rates were 69.4%and 28.1%at 1 and 3 years,respectively.Regarding pancreatic endo-exocrine insufficiency,16 patients(84.2%)lost weight,and 3 patients(15.8%)gained weight.Median pancreatic enzyme dosage was 60,000 U/d.Median stool frequency was 3 times/d,and diarrhea or steatorrhea happened in 12 cases(63.2%).Median BSFS score was 4.Sixteen patients(84.2%)said their stool condition gradually turned stable or better over time.Median blood glucose measurement frequency was 3 times/d.Median short-acting insulin dosage was 12 U/d,and long-acting insulin dosage was 9 U/d.Twelve patients(63.2%)suffered hypoglycemia within the last one month.Median HbAlc was 7.8%.Seventeen patients(89.5%)showed gradual stable or improved of blood glucose condition over time.The total scores of PAID20 and DTSQs were 24.87 and 25.89,respectively,which suggested acceptable satisfaction with diabetes-related problems and diabetes treatment.In terms of quality of life,QLQ-C30 suggested that the patients’postoperative quality of life decreased compared to the preoperative period,but the global health status was not significantly different(P=0.10).There were no significant differences between the young and old groups in operation time,intraoperative blood loss,postoperative morbidity rate,long-term survival,pancreatic endo-exocrine insufficiency management and quality of life.Conclusions:(1)Total pancreatectomy is one of the important surgical approaches for pancreatic diseases.It is a safe and feasible choice for some pancreatic diseases,and the incidence of postoperative morbidity and mortality can be well controlled;(2)The pancreatic endo-exocrine insufficiency after total pancreatectomy can be well controlled by decent alternative therapy and whole-process management,thus improving the quality of life of the patients;(3)Total pancreatectomy is also suitable for senior patients.Objective:To explore and evaluate the feasibility of total pancreatectomy in the treatment of pancreatic cancer by comparing the perioperative outcomes,long-term prognosis,and the effects on patients’ postoperative pancreatic endo-exocrine functions and quality of life between total pancreatectomy and pancreaticoduodenectomy.Materials and methods:The clinical and pathological data of 34 patients with pancreatic ductal adenocarcinoma(PDAC)undergoing total pancreatectomy in the Department of Hepatobiliary and Pancreatic Surgery,Beijing Hospital from January 2017 to January 2021(TP group)were retrospectively analyzed,and 34 patients with PDAC undergoing pancreaticoduodenectomy in the Department of Hepatobiliary and Pancreatic Surgery,Beijing Hospital from January 2017 to January 2021(PD group)were also randomly selected.Regular follow-ups were performed to acquire the survival of patients.Relevant information was collected from the still living patients with the Quality of Life Scale(QLQ-C30,v3.0 Chinese version),the Pancreatic Cancer Survival Quality Specific Scale(QLQ-PAN26,Chinese version),the Diabetes Related Issues Scale(PAID20,Chinese version),the Diabetes Treatment Satisfaction Scale(DTSQs,Chinese version)and selfadministered questionnaires(including blood glucose level,daily insulin dosage,daily pancreatic enzyme dose,stool condition,weight change,etc.).Comparative analysis was performed between the TP and PD groups.Results:Of all 68 cases,6 were lost to follow-up,21 were still alive,and 41 died.In the TP group,the median operation time was 385 min,intraoperative blood loss was 650 ml,median postoperative hospital stay was 20 days,and median total hospital cost was 121,448 yuan.Postoperative morbidity and mortality rates were 55.9%and 5.9%,respectively.Median overall survival time(OS)was 20 months,and OS rates at 1 and 3 years were 70.6%and 27.6%,respectively;median disease-free survival time(DFS)was 11 months,and median disease free survival rates at 1 and 3 years were 47.9%and 15.0%,respectively.In the PD group,the median operation time was 360 min,intraoperative blood loss was 600 ml,median postoperative hospital stay was 25 days,and median total hospital cost was 129,233 yuan.Postoperative morbidity and mortality rates were 67.6%and 0%,respectively;median OS was 21 months,and OS rates at 1 and 3 years were 70.6%and 27.6%,respectively;median DFS was 12 months,and DFS rates at 1 and 3 years were 44.1%and 14.5%,respectively.Eight patients(80%)in the TP group lost weight.Median pancreatic enzyme dosage was 60,000 U/d,6 patients(60%)had recent diarrhea,median BSFS score was 4.8.Median short-acting insulin dosage was 11 U/d and long-acting insulin dosage was 8 U/d.Six cases(60%)suffered hypoglycemia within the last one month.Median glycosylated hemoglobin(HbA1c)was 7.8%.The total score of PAID20 and DTSQs were 24.50 and 26.40,respectively.Eight cases(72.7%)in the PD group lost weight,8 cases(72.7%)had supplemental pancreatic enzymes,with median dosage of 40,000 U/d,recent diarrhea happened in 3 cases(27.3%),median BSFS score was 4,postoperative diagnosis of diabetes in 6 cases(54.5%),median short-acting insulin dosage 18 U/d and long-acting insulin dosage 6 U/d.Hypoglycemia happened in 3 cases(27.3%)within the last one month,median glycosylated hemoglobin(HbA1c)was 7.0%.The total scores of PAID20 and DTSQs were 20.21 and 30.00,respectively.There were no statistically differences between the two groups in the QLQ-C30 and QLQ-PAN26 scales in all domains.There were no significant differences between the TP and PD groups in terms of operation time,intraoperative blood loss,postoperative morbidity and mortality rates,OS,DFS,pancreatic endo-exocrine insufficiency management and quality of life,while the TP group had even shorter postoperative hospital stay(P=0.002).Conclusions:(1)Total pancreatectomy is a safe and effective surgical procedure for the treatment of pancreatic cancer.Compared with pancreaticoduodenectomy,there were no significant differences in postoperative morbidity,mortality,OS and DFS;(2)The pancreatic endo-exocrine insufficiency after total pancreatectomy can be effectively controlled by decent alternative therapy and whole-course management,and the quality of life is almost similar to that after pancreaticoduodenectomy.