Abstracts
BACKGROUND:
Pancreatic cancer has a high mortality rate due to late diagnosis and aggressive behavior. The prognosis is poor, with 5-year survival occurring in less than 5% of cases.
AIM:
To analyze demographic characteristics, comorbidities, type of procedure and early postoperative complications of patients with pancreatic cancer submitted to surgical treatment.
METHODS:
Cross-sectional study with analysis of 28 medical records of patients with malignant tumors of the pancreas in a 62 month. Data collection was performed from the medical records of the hospital.
RESULTS:
Of the total, 53,6% were male and the mean age was 60.25 years. According to the procedure, 53,6% was submitted to duodenopancreactectomy the remainder to biliodigestive derivation or distal pancreatectomy. The ductal adenocarcinoma occurred in 82,1% and 92,9% of tumors were located in the pancreatic head. Early postoperative complications occurred in 64,3% of cases and the most prevalent was intra-abdominal abscess (32,1%). Among duodenopancreactectomies 77,8% had early postoperative complications.
CONCLUSION:
Its necessary to encourage early detection of tumors of the pancreas to raise the number operations with curative intent. Refinements in surgical techniques and surgical teams can diminish postoperative complications and, so, operative morbimortality can also decrease over time.
Pancreatic neoplasms; Postoperative complications; Duodenopancreactectomy
RACIONAL:
O câncer de pâncreas apresenta alta taxa de mortalidade por conta do diagnóstico tardio e comportamento agressivo. O prognóstico é reservado com sobrevida de cinco anos em menos de 5% dos casos.
OBJETIVO:
Analisar as características demográficas, as comorbidades, o tipo de procedimento e as intercorrências pós-operatórias precoces dos pacientes de câncer de pâncreas submetidos ao tratamento cirúrgico.
MÉTODOS:
Estudo transversal, que analisou 28 prontuários de pacientes portadores de tumores malignos do pâncreas, no período de 62 meses. A coleta de dados foi realizada a partir dos prontuários médicos do hospital.
RESULTADOS:
Do total de participantes 53,6% eram do sexo masculino. A média de idade foi de 60,25 anos. Em relação ao procedimento, 53,6% foram submetidos à duodenopancreactectomia e o restante à derivação biliodigestiva ou pancreatectomia corpo-caudal. O adenocarcinoma ductal ocorreu em 82,1% e 92,9% dos tumores estavam localizados na cabeça do pâncreas. As complicações pós-operatórias precoces ocorreram em 64,3%, e a mais prevalente foi abscesso intra-abdominal (32,1%). Entre as duodenopancreatectomias, 77,8% apresentaram complicações pós-operatórias precoces.
CONCLUSÃO:
Há necessidade de se incentivar a detecção precoce dos tumores de pâncreas para que se consiga realizar mais operações com intenção curativa. Também, é necessário o aprimoramento das técnicas operatórias e das equipes cirúrgicas para que as complicações pós-operatórias e a morbimortalidade operatória diminuam ao longo do tempo.
Neoplasias pancreáticas; Complicacões pós-operatórias; Duodenopancreactectomia
INTRODUCTION
The incidence of pancreatic cancer in the United States is 13.6 per 100,000 in men and
10.7 per 100,000 in women1313. Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W,
Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis
DR, Chen HS, Feuer EJ, Cronin KA, Edwards BK (eds). SEER Cancer Statistics Review,
1975-2008, National Cancer Institute. Bethesda, MD, based on November 2010 SEER data
submission, posted to the SEER web site, 2011. [acesso 2011 Nov 06]. Disponível em:
http://seer.cancer.gov/csr/1975_2005/
http://seer.cancer.gov/csr/1975_2005/...
. In Brazil, this
disease is responsible for about 2% of all diagnosed cancers and 4% of all cancer
deaths44. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Instituto
Nacional de Câncer. Coordenação de Prevenção e Vigilância de Câncer. Estimativas
2008: Incidência de Câncer no Brasil. Rio de Janeiro: INCA; 2007. 94p. [acesso 2011
Nov 07]. Disponível em:
http://bvsms.saude.gov.br/bvs/publicacoes/estimativa_incidencia_cancer_2008.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
. The prognosis is poor, with a 5-year
survival of less than 5%77. Dragovich T, Harris JE. Pancreatic cancer. Updated: Sep 13, 2011.
[acesso 2011 Nov 07]. Disponível em:
http://emedicine.medscape.com/article/280605-overview
http://emedicine.medscape.com/article/28...
.
Ductal adenocarcinoma is preferentially localized to the head of the organ(47-65%),
followed by the body and tail (15-18%)88. Eloubeidi MA, Desmond RA, Wilcox CM, Wilson RJ, Manchikalapati P,
Fouad MM, Eltoum I, Vickers SM. Prognostic factors for survival in pancreatic cancer:
a population-based study. Am J Surg. 2006;192(3):322-9.. The
treatment of choice is surgical1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
, although not
all patients are candidates for this kind of treatment, in which postoperative
complications occur in 33.6%, most commonly due to infections (13.8%) followed by
pleural effusion (9.8%)1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
.
Patients with pancreatic cancer have been studied and observed over a long period of
time, and these studies report an increasing incidence of the disease3030. Winter JM, Brennan MF, Tang LH, D'Angelica MI, Dematteo RP, Fong Y,
Klimstra DS, Jarnagin WR, Allen PJ. Survival after Resection of Pancreatic
Adenocarcinoma: Results from a Single Institution over Three Decades. Ann Surg Oncol
[Internet]. 2011 Julho [Acesso em 2011 Ago 30];1900-3. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21761104
http://www.ncbi.nlm.nih.gov/pubmed/21761...
,
1717. Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G,
Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in
Calvados (France) from 1978 to 2002. Gastroenterol Clin Biol.
2009;33(10-11):1045-51.. However, there is also a study reporting a
decline2222. Luke C, Price T, Karapetis C, Singhal N, Roder D. Pancreatic cancer
epidemiology and survival in an Australian population. Asian Pac J Cancer Prev.
2009;10(3):369-74.. In any event, the prognosis is
bleak1010. Gupta S, Wang F, Holly EA, Bracci PM. Risk of pancreatic cancer by
alcohol dose, duration, and pattern of consumption, including binge drinking: a
population- based study. Cancer Causes Control. 2010;21(7):1047-59., but with improved long-term
survival2222. Luke C, Price T, Karapetis C, Singhal N, Roder D. Pancreatic cancer
epidemiology and survival in an Australian population. Asian Pac J Cancer Prev.
2009;10(3):369-74.
,
3030. Winter JM, Brennan MF, Tang LH, D'Angelica MI, Dematteo RP, Fong Y,
Klimstra DS, Jarnagin WR, Allen PJ. Survival after Resection of Pancreatic
Adenocarcinoma: Results from a Single Institution over Three Decades. Ann Surg Oncol
[Internet]. 2011 Julho [Acesso em 2011 Ago 30];1900-3. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21761104
http://www.ncbi.nlm.nih.gov/pubmed/21761...
,
66. Cronin-Fenton DP, Erichsen R, Mortensen FV, Dikinis S, Norgaard M,
Jacobsen J. Pancreatic cancer survival in central and northern Denmark from 1998
through 2009: a population-based cohort study. Clin. 2011; 3(Suppl 1):19-25. .
Thus, the objective of this study was to analyze the demographic characteristics, comorbidities, type of surgical procedure, and early postoperative complications in patients with pancreatic cancer undergoing surgery.
METHODS
This cross-sectional study was performed at the General Surgery Service of the Hospital Governador Celso Ramos, Florianópolis, SC, Brazil and approved by the Committee for Ethics in Research at the hospital.
The medical records of 28 patients, who underwent surgical treatment for pancreatic tumors between January, 2008 and February, 2013, were analyzed. The patient charts were obtained from the Medical Archive Service as well as hospital electronic records. The data were recorded on a data collection instrument built exclusively for this study, containing biological and clinical variables pertaining to tumor and postoperative characteristics. All charts of patients suffering from pancreatic cancer and subjected to surgical treatment of any kind were included in the study, and those who received surgical treatment for peritoneal carcinomatosis or those with insufficient chart data were excluded.
Results were entered into the Microsoft Excel Program (OU Epi-DATA) and exported to SPSS 16 (Statistical Package for the Social Sciences 16). Data were analyzed and described as absolute and relative frequencies. The Chi-square test or Fisher's exact test was utilized to test for homogeneity of proportions. The significance level was set to a value of p<0.05.
RESULTS
The medical records of 28 patients were analyzed. Fifteen (53.6%) were men. The average age was 60.25 years old (39-89). Weight varied between 44 and 90 kg, with a mean value of 64.8 kg. Three types of surgical procedure were studied.
The majority of patients (53.6%) underwent duodenopancreatectomy. Biliodigestive derivations, for palliative treatment, were performed in 39.3%. In both groups the neoplasms were localized to the head of the pancreas. In 7.1% of the patients, pancreatectomy of the tail and body was performed, since the neoplasm was localized to the body/tail.
Comorbidities of the participants, smoking, diabetes mellitus, alcoholism and systemic arterial hypertension were studied (Table 1).
The tumor characteristics analyzed were histological type, T stage and N (lymph node) stage (Table 2).
Values of the tumor marker CA 19-9 were collected from 24 patients. The analysis demonstrated that 50% of the patients had values ≤37 U/ml; 20.8%, between 37.1 and 369.9 U/ml; 29.2%, ≥370 U/ml, and 14.2% had no information concerning the marker. The values varied between 1.2 and 84476.5 U/ml.
The most common early surgical complications were intra-abdominal abscesses (32.1%), followed by delayed gastric emptying (25.0%), and pancreatic fistulas (21.4%). Among patients who underwent duodenopancreatectomy, four had a pancreatic fistula and two, pancreatic and biliary fistulas. Surgical reintervention for early postoperative complications of any kind occurred in five patients. Early non-surgical complications that stood out were respiratory (50.0%) - pneumonia and respiratory insufficiency - followed by cardiologic - acute myocardial infarction and atrial fibrillation - and renal - hypokalemia and metabolic acidosis (Table 3).
Male patients experienced 55.6% of all early postoperative complications. The diabetics experienced 44.4% of the complications, and smokers, 33.3% (Table 4).
Among participants in stage T3, 35.4% showed complications; amongT4 patients, only 17.6%; and all T1 and T2 patients showed early postoperative complications. There was a statistically significant association between the size of the tumor and all early postoperative complications (p=0.018) (Table 5).
Among patients undergoing duodenopancreatectomies, biliodigestive derivations, and body-tail pancreatectomies, 77.8%, 16.7%, and 5.6% showed complications, respectively. Diabetes mellitus was associated with the following postoperative complications: fistulas (the three types studied), infections (sepsis, surgical wound infections, and intra-abdominal abscesses), delayed gastric emptying and renal complications. Smoking was associated with surgical reintervention, fistulas and respiratory complications, and asthma was associated with fistulas (Table 6).
DISCUSSION
Cancer of the pancreas is most prevalent in men1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
,
1717. Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G,
Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in
Calvados (France) from 1978 to 2002. Gastroenterol Clin Biol.
2009;33(10-11):1045-51.
,
2222. Luke C, Price T, Karapetis C, Singhal N, Roder D. Pancreatic cancer
epidemiology and survival in an Australian population. Asian Pac J Cancer Prev.
2009;10(3):369-74.. Lowenfels and Maisonneuve attribute this to
the difference in the number of smokers, which is greater in males. This difference
tends to disappear due to increases in women smokers2020. Lowenfels AB, Maisonneuve P. Epidemiology of pancreatic cancer. In
Beger HG, Matsuno S, Cameron JL. Diseases of the pancreas: current surgical therapy.
Germany: ed. Springer-Verlag Berlin Heidelberg; 2008:489-94. or the tendency of women to live longer than men1717. Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G,
Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in
Calvados (France) from 1978 to 2002. Gastroenterol Clin Biol.
2009;33(10-11):1045-51.
,
99. Guarita DR, Felga GEG, Cunha JEM, Rocha MS. Tumores do pâncreas. In
Autores. Clínica médica, vol 4: doenças do aparelho digestivo, nutrição e doenças
nutricionais. SP - Barueri: ed. Manole; 2009.. Several authors point out that the predominant
age of patients with pancreatic cancer is above 60 years old1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
,
2222. Luke C, Price T, Karapetis C, Singhal N, Roder D. Pancreatic cancer
epidemiology and survival in an Australian population. Asian Pac J Cancer Prev.
2009;10(3):369-74.
,
1818. Lermite E, Pessaux P, Teyssedou C, Etienne S, Brehant O, Arnaud JP.
Effect of preoperative endoscopic biliary drainage on infectious morbidity after
pancreatoduodenectomy: a case- control study. Am J Surg.
2008;195(4):442-6.
,
1111. Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O,
Büchler MW, Werner J. Pancreatic Cancer Surgery in the New Millennium Better
Prediction of Outcome. Ann Surg. 2011;254(2):311-9.. Rocha et al.
2626. Rocha LCG, Queiroz FL, Eudes Magalha~es EA, Santos FAV, Caldeira
DAM, Ribas MA. Duodenopancreatectomia: Avaliação dos resultados em 41 pacientes. Rev.
Col. Bras. Cir. 2006;33(6):387-92. , analyzing patients in Belo Horizonte, Brazil,
reported a mean age of 59 years old, coinciding with world trends.
Cancers in patients undergoing duodenopancreatectomy progressed as far as stage
II-B2929. Union for International Cancer Control - UICC. TNM Classification of
Malignant Tumours -7th ed. 2010. [acesso em: 2012 Mar 15]. Disponível em:
http://www.uicc.org/resources/tnm
http://www.uicc.org/resources/tnm...
, and T3N1M0 occurred at the highest
frequency. When isolated tumors were studied, it was found that the majority (38.5%)
were grouped in stage T4. However, when the surgical procedure was analyzed, it was
found that the majority of patients underwent duodenopancreatectomy because they were in
stages T1-T3, that is, the sum total of the tumors staged in T1-T3 was greater than
those staged exclusively in T4, explaining the prevalence of duodenopancreatectomy as
the surgical procedure in this study rather than a palliative surgical procedure. Such
data are in accordance with other studies1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
,
1111. Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O,
Büchler MW, Werner J. Pancreatic Cancer Surgery in the New Millennium Better
Prediction of Outcome. Ann Surg. 2011;254(2):311-9. that recommend resection up to stage II-B.
However, Lefebvre et al.
1717. Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G,
Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in
Calvados (France) from 1978 to 2002. Gastroenterol Clin Biol.
2009;33(10-11):1045-51. and Abraham et al.
11. Abraham A, Al-Refaie WB, Parsons HM, Dudeja V, Vickers SM, Habermann
EB. Disparities in Pancreas Cancer Care. Ann Surg Oncol [Internet]. 2013 Abril
[acesso em 2013 Maio 15];10434-012. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/23579872
http://www.ncbi.nlm.nih.gov/pubmed/23579...
demonstrated a similar likelihood of curative
surgical operations in their studies, at around 11%.
Smoking is considered responsible for about 20-30% of pancreatic neoplasms in the western population1616. La Torre G, de Waure C, Specchia ML, Nicolotti N, Capizzi S, Bilotta A, Clemente G, Ricciardi W. Does quality of observational studies affect the results of meta-analysis? The case of cigarette smoking and pancreatic cancer. Pancreas. 2009 Apr;38(3):241-7. . Lowenfels et al. 2121. Lowenfels AB, Maisonneuve P, Whitcomb DC, Lerch MM, DiMagno EP. Cigarette smoking as a risk factor for pancreatic cancer in patients with hereditary pancreatitis. JAMA. 2001 Jul 11;286(2):169-70. showed that smokers develop pancreatic cancer between three and four years before non-smokers. The smoking population has a 70% greater risk of developing a pancreatic malignancy than the non-smoking population. To stop or never start smoking is considered a preventive factor2121. Lowenfels AB, Maisonneuve P, Whitcomb DC, Lerch MM, DiMagno EP. Cigarette smoking as a risk factor for pancreatic cancer in patients with hereditary pancreatitis. JAMA. 2001 Jul 11;286(2):169-70. , 2525. Muscat JE, Stellman SD, Hoffmann D, Wynder EL. Smoking and pancreatic cancer in men and women. Cancer Epidemiol Biomarkers Prev. 1997;6(1):15-9..
The incidence of diabetes melitus is higher in patients with pancreatic cancer, but the relationship between diabetes and cancer is controversial. Some studies indicate that diabetes is a risk factor for the development of pancreatic cancer, while others argue that diabetes could be a manifestation of cancer already in existence. Liao et al. 1919. Liao KF, Lai SW, Li CI, Chen WC. Diabetes mellitus correlates with increased risk of pancreatic cancer: A population-based cohort study in Taiwan. J Gastroenterol Hepatol. 2012;27(4):709-13. demonstrated that diabetic patients, less than two years after their initial diagnosis, have an increased incidence of pancreatic cancer. However, at longer periods following the diagnosis, patients show no significant difference. Chiari et al. 55. Chari ST, Leibson CL, Rabe KG, Timmons LJ, Ransom J, de Andrade M, Petersen GM. Pancreatic cancer-associated diabetes mellitus: prevalence and temporal association with diagnosis of cancer. Gastroenterology. 2008;134(1):95-101. observed that diabetes melitus can be an early manifestation of pancreatic cancer rather than a risk factor.
Preoperative alcoholic participants made up 1/4 of the total, but there were no records mentioning the quantity of alcoholic beverages consumed. The International Agency for Research on Cancer published a monograph on the evaluation of carcinogenic risks to humans and concluded that there was insufficient evidence to consider alcohol a risk factor for development of pancreatic cancer2727. Secretan B, Straif K, Baan R, Grosse Y, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Cogliano C. A review of human carcinogens-Part E: tobacco, areca nut, alcohol, coal smoke, and salted fish. Lancet Oncol. 2009;10(11):1033-4. . However, Gupta et al. 1010. Gupta S, Wang F, Holly EA, Bracci PM. Risk of pancreatic cancer by alcohol dose, duration, and pattern of consumption, including binge drinking: a population- based study. Cancer Causes Control. 2010;21(7):1047-59. support the occurrence of pancreatic cancer in the subgroup of patients exhibiting excessive alcohol consumption, independently of smoking.
Studies demonstrate a higher incidence of adenocarcinomas in relation to other histological types22. Amico EC, Alves JR, João SA, Guimarães PL, Barreto EJ, Barreto LS, Costa PR, Medeiros JA. Complications after pancreatectomies: prospective study after ISGFP and ISGPS new classifications. Arq Bras Cir Dig. 2013 Jul-Sep;26(3):213-8. and localization to the head of the pancreas88. Eloubeidi MA, Desmond RA, Wilcox CM, Wilson RJ, Manchikalapati P, Fouad MM, Eltoum I, Vickers SM. Prognostic factors for survival in pancreatic cancer: a population-based study. Am J Surg. 2006;192(3):322-9. , 1717. Lefebvre AC, Maurel J, Boutreux S, Bouvier V, Reimund JM, Launoy G, Arsene D. Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002. Gastroenterol Clin Biol. 2009;33(10-11):1045-51. , 1111. Hartwig W, Hackert T, Hinz U, Gluth A, Bergmann F, Strobel O, Büchler MW, Werner J. Pancreatic Cancer Surgery in the New Millennium Better Prediction of Outcome. Ann Surg. 2011;254(2):311-9..
The tumor marker most commonly utilized in the diagnosis and prognosis of exocrine pancreatic cancer is the tumor-associated carbohydrate antigen 19-9 (CA 19-9). Around 70-90% of patients with pancreatic cancer express this marker in a manner sensitive to the stage of the disease2525. Muscat JE, Stellman SD, Hoffmann D, Wynder EL. Smoking and pancreatic cancer in men and women. Cancer Epidemiol Biomarkers Prev. 1997;6(1):15-9.. It is not uncommon to find patients with small tumors but normal values of CA19-9. It is thought that the marker is elevated in only half of the patients with tumors of 2 cm or less33. Beger HG, Matsuno S, Cameron JL. Diseases of the Pancreas - Current Surgical Therapy. Berlin: Springer, 2008.. Kim et al. 1515. Kim HJ, Kim MH, Myung SJ, Lim BC, Park ET, Yoo KS, Seo DW, Lee SK, Min YI. A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve. Am J Gastroenterol. 1999;94(7):1941-6. found that, at its cut-off value of 37 U/ml, its sensitivity and specificity were 76.7% and 87.1 %, respectively. Patients with very high levels of CA 19-9 (more than 1000 U/ml) are very likely to have inoperable cancer33. Beger HG, Matsuno S, Cameron JL. Diseases of the Pancreas - Current Surgical Therapy. Berlin: Springer, 2008..
Lermite et al. 1818. Lermite E, Pessaux P, Teyssedou C, Etienne S, Brehant O, Arnaud JP. Effect of preoperative endoscopic biliary drainage on infectious morbidity after pancreatoduodenectomy: a case- control study. Am J Surg. 2008;195(4):442-6. state that intra-abdominal abscesses are frequently associated with pancreatic and biliary fistulas. Diagnosis of a suspected fistula can be made by means of clinical data and confirmed by biochemical methods and imaging. In the present study, diagnosis of this complication was based solely on clinical observation, because the method used to confirm the diagnosis was not mentioned in the chart records, only the presence or absence of the complication. Therefore, in the diagnosis of a fistula, the characteristics of the drained liquid were taken into account; except in a few cases in which amylase was measured in the drained liquid, no laboratory testing or imaging was used to study this. A digestive fistula was considered one whose liquid contained gastrointestinal secretions. A biliary fistula was considered one whose liquid was yellow-brown in color with crystals in the pancreatic liquid.
Pancreatic fistulas occur in 10-15% of patients subjected to duodenopancreatectomy, in
agreement with Lermite et al.
1818. Lermite E, Pessaux P, Teyssedou C, Etienne S, Brehant O, Arnaud JP.
Effect of preoperative endoscopic biliary drainage on infectious morbidity after
pancreatoduodenectomy: a case- control study. Am J Surg.
2008;195(4):442-6.. However, as this complication depends on
various factors, there are investigators who report a lower rate. Kamphues et
al.
1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
found them in 1.4% of 442 surgically treated
patients and Amico et al.22. Amico EC, Alves JR, João SA, Guimarães PL, Barreto EJ, Barreto LS,
Costa PR, Medeiros JA. Complications after pancreatectomies: prospective study after
ISGFP and ISGPS new classifications. Arq Bras Cir Dig. 2013
Jul-Sep;26(3):213-8., in
50% of 54 surgically treated patients. Among the local factors related to the genesis of
pancreatic fistulas, the consistency of the pancreatic remnant (soft, normal or hard)
and the caliber of the pancreatic ducts are noteworthy. Subjective evaluation of the
greater consistency of the pancreas, associated with ductal dilatation, contributed to a
lower incidence of pancreatic fistulas2323. Matheus AS, Montagnini AL, Jukemura J, Jurendini R, Penteado S, Abdo
EE, Cunha JEM. Risk factors for pancreatic fistula. Does it have a clinical
application for early identification of patients with high risk to develop pancreatic
fistula after pancreaticoduodenectomy? . Gastroenterol 2006;130(4)
supl2.. In the
indicated study, this complication was unrelated to the consistency of the gland or to
the type of anastomosis used (duct-to-mucosa or telescoping of the pancreatic stump).
Delayed gastric emptying is, by definition, persistent gastric stasis requiring nasogastric aspiration for a period of at least 10 days or solid food intolerance for up to 14 postoperative days. Various factors are related to the onset of this complication, notably previous abdominal operations, diabetes, malnutrition and postoperative intra-abdominal complications1212. Henegouwen MB, van Gulik TM, DeWit LT, Allema JH, Rauws EAJ, Obertop H, Gouma DJ. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg. 1997;185(4):388-95..
According to Kamphues et al.
1414. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
, the most common non-surgical complication was
of the cardiopulmonary type, occurring in 12.4% of the patients undergoing
duodenopancreatectomy, and surgical reintervention took place in 10.3% of the cases.
Already in the study of Rocha et al.
2626. Rocha LCG, Queiroz FL, Eudes Magalha~es EA, Santos FAV, Caldeira
DAM, Ribas MA. Duodenopancreatectomia: Avaliação dos resultados em 41 pacientes. Rev.
Col. Bras. Cir. 2006;33(6):387-92. , the nonsurgical complication that occurred
the most was pneumonia (12.2%) along with surgical wound infection (12.2%). In the
present study, total early postoperative complications came to 64.3%. This observation
is at variance with Kamphues et al.
14 14. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F,
Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M. Postoperative
Complications Deteriorate Long-Term Outcome in Pancreatic Cancer Patients. Ann Surg
Oncol [Internet] . 2011 Abril [acesso em 2011 Ago 30]; 2041-4. Disponível em:
http://www.ncbi.nlm.nih.gov/pubmed/21879265
http://www.ncbi.nlm.nih.gov/pubmed/21879...
and in harmony with Rocha et
al.
2626. Rocha LCG, Queiroz FL, Eudes Magalha~es EA, Santos FAV, Caldeira
DAM, Ribas MA. Duodenopancreatectomia: Avaliação dos resultados em 41 pacientes. Rev.
Col. Bras. Cir. 2006;33(6):387-92. , who obtained values of 33.6 and 58%,
respectively. In the study under discussion, 77.8% of the patients who underwent
duodenopancreatectomy showed early complications postoperatively; among those subjected
to biliodigestive derivation, only 16.7%; and among the remaining patients, who
underwent corpocaudal pancreatectomy, 5.6%, Theoretically, one would expect to find a
higher frequency of complications in patients undergoing duodenopancreatectomy when
compared to those subjected to corpocaudal pancreatectomy. In the former case, the
procedure is technically more complex, resulting in a longer period in surgery and the
eventual need for a blood transfusion. In the latter case, the number of patients with
tumors of the pancreatic body and tail was decidedly small, when compared with tumors of
the head (based on the frequency of malignant tumors localized to the pancreas), and as
a consequence, corpocaudal pancreatectomy was performed only a few times. Perhaps more
instances of this procedure would reduce such a difference. A similar explanation may
apply to cases in which the patients underwent biliodigestive derivation.
CONCLUSION
There is a need to encourage early detection of pancreatic tumors to increase the number of operations with curative potential. Refinements in surgical techniques and surgical teams could also diminish postoperative complications and thereby decrease operative morbimortality over time.
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Financial source: none
Publication Dates
-
Publication in this collection
Nov-Dec 2014
History
-
Received
25 Mar 2014 -
Accepted
26 June 2014