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Pancreatic Neoplasms: HELP
Articles by Zhi Ven Fong
Based on 18 articles published since 2010
(Why 18 articles?)
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Between 2010 and 2020, Zhi Ven Fong wrote the following 18 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
1 Review Intraductal Papillary Mucinous Neoplasm of the Pancreas. 2016

Fong, Zhi Ven / Fernández-Del Castillo, Carlos. ·Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114-3117, USA. · Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114-3117, USA. Electronic address: cfernandez@partners.org. ·Surg Clin North Am · Pubmed #27865286.

ABSTRACT: The incidence of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas has been rising in the past 2 decades, driven mainly by the widespread use of cross-sectional imaging. IPMNs are intraductal mucin-producing neoplasms that involve the main pancreatic duct or its side branches and lack the ovarian stroma typically seen in mucinous cystic neoplasms. The International Association of Pancreatology released consensus guidelines in 2006 and 2012 providing clinical algorithms based on IPMN features and risk of malignancy. In this article, we review the different classifications of IPMNs, their natural history, and clinical management and address recent controversies in the literature.

2 Review Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current State of the Art and Ongoing Controversies. 2016

Fong, Zhi Ven / Ferrone, Cristina R / Lillemoe, Keith D / Fernández-Del Castillo, Carlos. ·Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. ·Ann Surg · Pubmed #26727096.

ABSTRACT: With the widespread use and advances in radiographic imaging, Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas are identified with increasing frequency. Although many studies have addressed its biology and treatment, true understanding of its natural history continues to elude us. Its malignant potential places careproviders in a clinical dilemma of balancing the morbidity of pancreatectomy against the risk of malignant transformation while under continuous surveillance. Recently, there have been conflicting data published in the literature, generating more uncertainty in the field. In this article, we critically analyze the contrasting consensus guidelines from the International Association of Pancreatology and the American Gastroenterology Association, and address lingering questions and controversies. We also synthesize newly published data in the context of current standard of care, and provide a comprehensive review and recommendations for the clinical diagnosis, treatment, and follow-up strategy in the management of patients with Intraductal Papillary Mucinous Neoplasms.

3 Review Biomarkers in pancreatic cancer: diagnostic, prognostic, and predictive. 2012

Fong, Zhi Ven / Winter, Jordan M. ·Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. zfong@partners.org ·Cancer J · Pubmed #23187839.

ABSTRACT: Pancreatic cancer is the fourth leading cause of cancer-related death in the United States. There has been minimal progress with regard to cancer-specific outcomes in recent decades. Although effective therapies will undoubtedly change the natural history of the disease, effective biomarkers are a promising tool that will likely have a positive impact and will undoubtedly have an important role in the management of patients with pancreatic ductal adenocarcinoma (PDA) in the future. At present, serum CA-19-9 (carbohydrate antigen 19-9) is the only Food and Drug Administration-approved biomarker for PDA, and it has utility as a prognostic marker and as a marker of disease recurrence. There has been a recent explosion in the pancreatic cancer biomarker field with more than 2000 biomarker studies implicating thousands of informative genes as candidate biomarkers. In this review, we summarize the literature on CA-19-9 in PDA and highlight the most promising investigational biomarkers. Distinctions are made between diagnostic biomarkers (detection of disease), prognostic biomarkers (provide information on prognosis and recurrence pattern), and predictive biomarkers (predict treatment response).

4 Article Core Set of Patient-reported Outcomes in Pancreatic Cancer (COPRAC): An International Delphi Study Among Patients and Health Care Providers. 2019

van Rijssen, Lennart B / Gerritsen, Arja / Henselmans, Inge / Sprangers, Mirjam A / Jacobs, Marc / Bassi, Claudio / Busch, Olivier R / Fernández-Del Castillo, Carlos / Fong, Zhi Ven / He, Jin / Jang, Jin-Young / Javed, Ammar A / Kim, Sun-Whe / Maggino, Laura / Mitra, Abhishek / Ostwal, Vikas / Pellegrini, Silvia / Shrikhande, Shailesh V / Wilmink, Johanna W / Wolfgang, Christopher L / van Laarhoven, Hanneke W / Besselink, Marc G / Anonymous531066. ·Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands. · Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands. · Department of Medical Psychology, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands. · General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. · Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD. · Department of Surgery, Seoul National University Hospital, Seoul, Korea. · GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India. · Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India. · Department of Medical Psychology, University of Verona Hospital Trust, Verona, Italy. · Department of Medical Oncology, Cancer Center Amsterdam Academic Medical Center, Amsterdam, The Netherlands. ·Ann Surg · Pubmed #29261524.

ABSTRACT: OBJECTIVE: To establish an international core set of patient-reported outcomes (PROs) selected by both patients and healthcare providers (HCPs) from the United States (US), Europe, and Asia. SUMMARY BACKGROUND DATA: PROs are increasingly recognized in pancreatic cancer studies. There is no consensus on which of the many available PROs are most important. METHODS: A multicenter Delphi study among patients with pancreatic cancer (curative- and palliative-setting) and HCPs in 6 pancreatic centers in the US (Baltimore, Boston), Europe (Amsterdam, Verona), and Asia (Mumbai, Seoul) was performed. In round 1, participants rated the importance of 56 PROs on a 1 to 9 Likert scale. PROs rated as very important (scores 7-9) by the majority (≥80%) of curative- and/or palliative-patients as well as HCPs were included in the core set. PROs not fulfilling these criteria were presented again in round 2, together with feedback on individual and group ratings. Remaining PROs were ranked based on the importance ratings. RESULTS: In total 731 patients and HCPs were invited, 501 completed round 1, and 420 completed both rounds. This included 204 patients in curative-setting, 74 patients in palliative-setting, and 142 HCPs. After 2 rounds, 8 PROs were included in the core set: general quality of life, general health, physical ability, ability to work/do usual activities, fear of recurrence, satisfaction with services/care organization, abdominal complaints, and relationship with partner/family. CONCLUSIONS: This international Delphi study among patients and HCPs established a core set of PROs in pancreatic cancer, which should facilitate the design of future pancreatic cancer trials and outcomes research.

5 Article Are Staging Computed Tomography (CT) Scans of the Chest Necessary in Pancreatic Adenocarcinoma? 2018

Mehtsun, Winta T / Chipidza, Fallon E / Fernández-Del Castillo, Carlos / Hemingway, Katherine / Fong, Zhi Ven / Chang, David C / Pandharipande, Pari / Clark, Jeffrey W / Allen, Jill / Hong, Theodore S / Wo, Jennifer Y / Warshaw, Andrew L / Lillemoe, Keith D / Ferrone, Cristina R. ·Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. · Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA. · Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA. · Department of Radiology, Massachusetts General Hospital, Boston, MA, USA. · Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA. · Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. cferrone@partners.org. ·Ann Surg Oncol · Pubmed #30276641.

ABSTRACT: BACKGROUND: There is no consensus on the use of chest imaging in pancreatic ductal adenocarcinoma (PDAC) patients. Among PDAC patients, we examined the use of chest computed tomography (CT) over time and determined whether the use of chest CT led to a survival difference or change in management via identification of indeterminate lung nodules (ILNs). METHODS: Retrospective clinical data was collected for patients diagnosed with PDAC from 1998 to 2014. We examined the proportion of patients undergoing staging chest CT scan and those who had ILN, defined as ≥ 1 well-defined, noncalcified lung nodule(s) ≤ 1 cm in diameter. We determined time to overall survival (OS) using multivariate Cox regression. We also assessed changes in management of PDAC patients who later developed lung metastasis only. RESULTS: Of the 2710 patients diagnosed with PDAC, 632 (23%) had greater than one chest CT. Of those patients, 451 (71%) patients had ILNs, whereas 181 (29%) had no ILNs. There was no difference in median overall survival in patients without ILNs (16.4 [13.6, 19.0] months) versus those with ILN (14.8 [13.6, 15.8] months, P = 0.18). Examining patients who developed isolated lung metastases (3.3%), we found that staging chest CTs did not lead to changes in management of the primary abdominal tumor. CONCLUSIONS: Survival did not differ for PDAC patients with ILNs identified on staging chest CTs compared with those without ILNs. Furthermore, ILN identification did not lead to changes in management of the primary abdominal tumor, questioning the utility of staging chest CTs for PDAC patients.

6 Article Staging Laparoscopy Not Only Saves Patients an Incision, But May Also Help Them Live Longer. 2018

Sell, Naomi M / Fong, Zhi Ven / Del Castillo, Carlos Fernandez / Qadan, Motaz / Warshaw, Andrew L / Chang, David / Lillemoe, Keith D / Ferrone, Cristina R. ·Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. · Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. cferrone@mgh.harvard.edu. ·Ann Surg Oncol · Pubmed #29388123.

ABSTRACT: BACKGROUND: Approximately 20-40% of patients with "resectable" pancreatic adenocarcinoma (PDAC) by imaging criteria have metastatic disease on exploration. Our aim was to assess the potential impact of staging laparoscopy versus upfront laparotomy in "resectable" patients found to have metastatic PDAC. METHODS: Clinicopathologic data was retrospectively collected for all patients with PDAC undergoing an operation with curative intent between 2001-2015 at a single institution. RESULTS: Of the 1001 patients undergoing surgical evaluation, 151 had unsuspected metastatic PDAC. Staging laparoscopy was performed in 59% (89/151) of patients, while 41% (62/151) underwent an exploratory laparotomy with or without prophylactic bypass. There were no differences in patient demographics and preoperative CA 19-9 levels between the staging laparoscopy and exploratory laparotomy groups. However, staging laparoscopy was more often performed for pancreatic body/tail lesions (85% vs 60% for pancreatic head lesions, p < 0.001). Patients who only underwent laparoscopy started palliative chemotherapy more quickly (17.9 days vs 39.9 days in the laparotomy group, p < 0.001). There was no difference in the 30 day or lifetime incidence of postoperative cholangitis, gastric outlet obstruction, or biliary stent placement between groups. The median overall survival for the staging laparoscopy group (11.4 months) was significantly longer than the laparotomy group (8.3 months, p < 0.001). In a cox regression analysis adjusting for clinicopathologic variables, staging laparoscopy was associated with significantly improved overall survival when compared to the laparotomy group (HR 0.53, 95% C.I. 0.34-0.82, p = 0.005). CONCLUSION: For patients diagnosed with metastatic PDAC at the time of surgical exploration, staging laparoscopy was associated with a shorter time to chemotherapy and improved overall survival when compared to those explored without laparoscopy.

7 Article Impact of Treatments on Diabetic Control and Gastrointestinal Symptoms After Total Pancreatectomy. 2017

Struyvenberg, Maarten R / Fong, Zhi Ven / Martin, Camilia R / Tseng, Jennifer F / Clancy, Thomas E / Fernández-Del Castillo, Carlos / Tillman, Hanna J / Bellin, Melena D / Freedman, Steven D. ·From the *Department of Gastroenterology, Beth Israel Deaconess Medical Center; †Department of Surgery, Massachusetts General Hospital; ‡Department of Neonatology, Beth Israel Deaconess Medical Center; and §Department of Surgery, Brigham and Women's Hospital, Boston, MA; and ∥Department of Pediatric Endocrinology, University of Minnesota Medical Center, Minneapolis, MN. ·Pancreas · Pubmed #28902790.

ABSTRACT: OBJECTIVES: The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage. METHODS: Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions. RESULTS: Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes. CONCLUSIONS: After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.

8 Article Reappraisal of Staging Laparoscopy for Patients with Pancreatic Adenocarcinoma: A Contemporary Analysis of 1001 Patients. 2017

Fong, Zhi Ven / Alvino, Donna Marie L / Fernández-Del Castillo, Carlos / Mehtsun, Winta T / Pergolini, Ilaria / Warshaw, Andrew L / Chang, David C / Lillemoe, Keith D / Ferrone, Cristina R. ·Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. · Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. · Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. cferrone@partners.org. ·Ann Surg Oncol · Pubmed #28718038.

ABSTRACT: BACKGROUND: Recent advances in imaging and the increasing use of neoadjuvant therapy puts the contemporary utility of staging laparoscopy for patients with pancreatic adenocarcinoma (PDAC) into question. This study aimed to develop a prognostic score to optimize prevention of an unnecessary laparotomy and minimize the rate for unnecessary laparoscopy. METHODS: Clinicopathologic data were evaluated for all patients undergoing surgical intervention for PDAC between 2001 and 2015, who were stratified into group 1 (2001-2008) and group 2 (2009-2014). RESULTS: The study identified 1001 patients eligible for analysis, 331 (33%) of whom underwent a staging laparoscopy before exploration. An unnecessary laparotomy was prevented for 44.4% of the patients in period 1 and for 24% of the patients in period 2 (p < 0.001). Male gender [odds ratio (OR), 1.8; p < 0.05], preoperative resectability (borderline resectable OR 2.1; p < 0.019; locally advanced OR 7.6; p < 0.001), CA 19-9 levels higher than 394 U/L (OR 3.1; p < 0.001), no neoadjuvant chemotherapy (OR 2.7; p = 0.012), and pancreatic body or tail lesions (OR 1.8; p = 0.063) were predictive of occult metastatic disease. The developed scoring index demonstrated a c-statistic of 0.729. The observed-to-expected ratio for the index at every score level validated the index's model. A score cutoff at 4 was able to detect 76.1% of radiographically occult metastatic disease. CONCLUSION: The rate for unnecessary laparotomy among patients with PDAC has decreased in contemporary times, but unnecessary laparotomy still occurs for 1 in 4 patients. Using our scoring system, a cutoff of 4 allows 76% of radiographically occult metastases to be predicted, thereby selecting high-risk patients for laparoscopic biopsy and potentially avoiding a non-therapeutic laparotomy.

9 Article Health-related Quality of Life and Functional Outcomes in 5-year Survivors After Pancreaticoduodenectomy. 2017

Fong, Zhi Ven / Alvino, Donna M / Castillo, Carlos Fernández-Del / Nipp, Ryan D / Traeger, Lara N / Ruddy, Margaret / Lubitz, Carrie C / Johnson, Colin D / Chang, David C / Warshaw, Andrew L / Lillemoe, Keith D / Ferrone, Cristina R. ·*Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA †Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA ‡Department of Psychology, Massachusetts General Hospital, Harvard Medical School, Boston, MA §Department of Surgery, University of Southampton, Southampton, UK. ·Ann Surg · Pubmed #28657944.

ABSTRACT: OBJECTIVE: Our aim was to assess quality of life (QOL) and functionality in a large cohort of patients ≥5-years after pancreaticoduodenectomy (PD). BACKGROUND: Long-term QOL outcomes after PD for benign or malignant disease are largely undocumented. METHODS: We administered the EORTC QLQ-C30 questionnaire to patients who underwent PD for neoplasms from 1998 to 2011 and compared their scores with an age- and sex-matched normal population. Clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (>20) based on validated interpretation of clinically important differences. RESULTS: Of 305 PD survivors, 245 (80.3%) responded, of whom 157 (64.1%) underwent PD for nonmalignant lesions. Median follow-up was 9.1 years (range 5.1 -21.2 yrs). New-onset diabetes developed in 10.6%; 50.4% reported taking pancreatic enzymes; 54.6% reported needing antacids. Compared with the age- and sex-adjusted controls, PD survivors demonstrated higher global QOL (78.7 vs 69.7, CR small, P < 0.001), physical (86.7 vs 77.9, CR small, P < 0.001) and role-functioning scores (86.3 vs 74.1, CR medium, P < 0.001). Using linear regression and adjusting for socioeconomic variables, there were no differences in QOL or functional scores in the benign versus malignant subgroups. Older age at operation was associated with worse physical-functioning (-0.4/yr, P = 0.008). Taking pancrelipase (-6.8, P = 0.035) or antacids (-6.3, P = 0.044) were both associated with lower social-functioning scores. CONCLUSIONS: Patients who had a PD demonstrated better global QOL, physical- and role-functioning scores at 5-years when compared with age- and sex-matched controls. Approximately half of the patients required pancreatic enzyme replacement, while only 11% developed new-onset diabetes.

10 Article Microscopic lymphovascular invasion is an independent predictor of survival in resected pancreatic ductal adenocarcinoma. 2017

Epstein, Jeffrey D / Kozak, Geoffrey / Fong, Zhi Ven / He, Jin / Javed, Ammar A / Joneja, Upasana / Jiang, Wei / Ferrone, Cristina R / Lillemoe, Keith D / Cameron, John L / Weiss, Matthew J / Lavu, Harish / Yeo, Charles J / Fernandez-Del Castillo, Carlos / Wolfgang, Christopher L / Winter, Jordan M. ·Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. · Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. · Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. · Department of Surgical Oncology, Johns Hopkins Hospital, Baltimore, Maryland. · Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. ·J Surg Oncol · Pubmed #28628722.

ABSTRACT: Background and Objectives Despite routine inclusion of lymphovascular invasion (LVI) status in pathologic reports of resected pancreatic ductal adenocarcinomas (PDA), the clinical implications of LVI have not been well characterized. Methods This study is a retrospective review of 2640 patients who underwent a pancreatectomy for PDA at Thomas Jefferson University Hospital, Massachusetts General Hospital, or Johns Hopkins Hospital (2003-2014). Clinical and pathologic records were extracted from institutional databases. Results The median post-resection survival for the total cohort was 19.2 months with a 5-year survival rate of 15.2%. In a multivariate Cox proportional hazards model including conventional pathologic features, LVI was an independent predictor of survival (HR = 1.14, P = 0.017). In a stratified Kaplan-Meier survival analysis, patients with N0, LVI- PDA had a significantly improved overall survival compared to those with N0, LVI+ PDA (median 31 vs 24 mo, P = 0.020). Similarly, patients with N1, LVI- PDA had superior survival to patients with N1, LVI+ disease (18.6 vs 16.5 mo, P = 0.001). Conclusions As the first large scale study focused on the clinical impact of LVI status in PDA, these data indicate that this routinely reported pathologic feature is a bona fide and independent adverse prognostic factor.

11 Article Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: a large single center experience from the Massachusetts General Hospital. 2016

Sahora, Klaus / Morales-Oyarvide, Vicente / Ferrone, Cristina / Fong, Zhi Ven / Warshaw, Andrew L / Lillemoe, Keith D / Fernández-del Castillo, Carlos. ·Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 460, 15 Parkman Street, Boston, MA 02114, USA. · Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 460, 15 Parkman Street, Boston, MA 02114, USA. cfernandez@partners.org. ·J Hepatobiliary Pancreat Sci · Pubmed #26768943.

ABSTRACT: BACKGROUND: The impact of preoperative biliary drainage (PBD) on perioperative morbidity and mortality in pancreatic surgery is still under debate. The aim of this study was to investigate outcomes of stented vs. non-stented patients undergoing pancreatoduodenectomy (PD). METHODS: We retrospectively compared 500 consecutive patients who underwent PBD prior to PD with 500 patients who did not. Ninety-day mortality and morbidity were assessed. RESULTS: The overall postoperative morbidity and mortality was 37% and 1.4%, respectively. Major complications (Clavien ≥ III) occurred in 16% of patients. The overall morbidity and mortality was not significantly higher in patients who underwent PBD. However, the rate of wound infection was significantly higher in patients who underwent PBD (19% vs. 9%, P = 0.001). When comparing intraoperative bile cultures of stented patients with and without wound infection, the presence of Enterobacter species (OR 2.4, 95% CI 1.5-4.1, P = 0.001) and Citrobacter species (OR 2.3, 95% CI 1.1-5.2, P = 0.037) in the bile significantly increased the likelihood of wound infection. CONCLUSION: Preoperative biliary drainage is associated with bactobilia and wound infection, but does not affect the overall morbidity and mortality of patients undergoing PD.

12 Article Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation. 2016

McMillan, Matthew T / Soi, Sameer / Asbun, Horacio J / Ball, Chad G / Bassi, Claudio / Beane, Joal D / Behrman, Stephen W / Berger, Adam C / Bloomston, Mark / Callery, Mark P / Christein, John D / Dixon, Elijah / Drebin, Jeffrey A / Castillo, Carlos Fernandez-Del / Fisher, William E / Fong, Zhi Ven / House, Michael G / Hughes, Steven J / Kent, Tara S / Kunstman, John W / Malleo, Giuseppe / Miller, Benjamin C / Salem, Ronald R / Soares, Kevin / Valero, Vicente / Wolfgang, Christopher L / Vollmer, Charles M. ·*Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania†Department of Surgery, Mayo Clinic, Jacksonville, Florida‡Department of Surgery, University of Calgary, Calgary, Canada§Department of Surgery, University of Verona, Verona, Italy¶Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana||Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee**Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania††Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio‡‡Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts§§Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama¶¶Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts||||Department of Surgery, Baylor College of Medicine, Houston, Texas***Department of Surgery, University of Florida College of Medicine, Gainesville, Florida†††Department of Surgery, Yale School of Medicine, New Haven, Connecticut‡‡‡Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland. ·Ann Surg · Pubmed #26727086.

ABSTRACT: OBJECTIVE: To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. BACKGROUND: Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. METHODS: This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. RESULTS: There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. CONCLUSIONS: This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

13 Article Recurrence and Survival After Resection of Small Intraductal Papillary Mucinous Neoplasm-associated Carcinomas (≤20-mm Invasive Component): A Multi-institutional Analysis. 2016

Winter, Jordan M / Jiang, Wei / Basturk, Olca / Mino-Kenudson, Mari / Fong, Zhi Ven / Tan, Wei Phin / Lavu, Harish / Vollmer, Charles M / Furth, Emma E / Haviland, Dana / Klimstra, David S / Jarnagin, William R / Lillemoe, Keith D / Yeo, Charles J / Fernandez-Del Castillo, Carlos / Allen, Peter J. ·*Department of Surgery and the Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA †Department of Pathology, Thomas Jefferson University, Philadelphia, PA ‡Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY §Department of Pathology, Massachusetts General Hospital, Boston, MA ¶Department of Surgery, Massachusetts General Hospital, Boston, MA ||Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA **Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA ††Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY. ·Ann Surg · Pubmed #26135696.

ABSTRACT: BACKGROUND: Early invasive carcinoma may be encountered in association with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. The natural history of these early invasive lesions is unknown. METHODS: Pancreatic surgical databases from 4 high-volume centers were queried for IPMNs, with invasive components measuring 20 mm or less. All cases were reviewed by GI gastrointestinal pathologists, and pathologic features were analyzed to identify predictors of recurrence and survival. RESULTS: A total of 70 small IPMN-associated invasive carcinomas (≤20-mm invasion) were identified, comprising 25% of resected IPMN-associated carcinomas (n = 280). Most of these small invasive cancers were multifocal (66%), less than 10 mm in size (73%), and arose in the setting of a main duct IPMN (96%). The most common adenocarcinoma subtypes were tubular (57%) and colloid (29%). Lymph node metastases were present in 19% of cases and 23% were T3 lesions. The overall recurrence rate was 24% (n = 17), and the median time to recurrence was 16 months (range: 4-132 months). Median and 5-year survival rates were 99 months and 59%. Recurrence patterns of invasive disease were local in 35%, distant in 47%, and both in 18%. Lymphatic spread and T3 stage were predictive of recurrence (univariate, P = 0.006), whereas tubular carcinoma type was the most predictive of poor overall survival (multivariate hazard ratio = 3.7, P = 0.04). CONCLUSIONS: This study represents the largest multi-institutional experience of resected small IPMN-associated carcinoma. Although these malignancies may frequently be cured with resection, recurrence risk is significant. Lymphatic spread, increased T stage, and tubular type carcinoma were associated with the poorest outcome.

14 Article High performing whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy. 2014

Lee, Grace C / Fong, Zhi Ven / Ferrone, Cristina R / Thayer, Sarah P / Warshaw, Andrew L / Lillemoe, Keith D / Fernández-del Castillo, Carlos. ·Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA. ·J Gastrointest Surg · Pubmed #25091843.

ABSTRACT: INTRODUCTION: Despite the decreasing mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged length of postoperative hospital stay (LOS). This study aimed to determine factors that could predict short LOS after PD. Additionally, as preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume center to set a standard to which minimally invasive PD can be compared. METHODS: A total of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at the Massachusetts General Hospital comprised the study cohort. "High performers" were defined as patients with postoperative LOS ≤5 days. RESULTS: Median LOS was 7 days. A total of 61 patients (9.6%) had LOS ≤5 days and were deemed "high performing." In multivariate logistic regression analysis, male gender (p = 0.032), neoadjuvant chemoradiation (p = 0.001), epidural success (p = 0.019), epidural duration ≤3 days (p = 0.001), lack of complications (p < 0.001), surgery on Thursday or Friday (p = 0.001), and discharge on Monday through Wednesday (p < 0.001) were independently associated with LOS ≤5 days. Readmission rate, time to readmission, and mortality were not different between the two groups. The proportion of patients with pancreatic ductal adenocarcinoma who went on to receive adjuvant therapy was no different if LOS was ≤5 or >5 days, but high performance was predictive of beginning therapy <8 weeks after surgery (p = 0.010). CONCLUSION: In our experience, median LOS was 7 days, and early discharge (≤5 days) after open PD is safe and feasible in about 10 % of patients. These high performers are more likely to be male, have received neoadjuvant therapy, and had successful epidural analgesia. High performers with cancer are more likely to start chemotherapy <8 weeks after surgery. Minimally invasive PD should be compared to this high standard for median LOS, among other quality metrics, to justify its increased cost, operative duration, and learning curve.

15 Article Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings. 2013

Fong, Zhi Ven / Tan, Wei Phin / Lavu, Harish / Kennedy, Eugene P / Mitchell, Donald G / Koniaris, Leonidas G / Sauter, Patricia K / Rosato, Ernest L / Yeo, Charles J / Winter, Jordan M. ·Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. ·J Gastrointest Surg · Pubmed #23553385.

ABSTRACT: BACKGROUND: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. METHODS: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. RESULTS: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). DISCUSSION: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

16 Article A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes? 2013

Carter, Timothy I / Fong, Zhi Ven / Hyslop, Terry / Lavu, Harish / Tan, Wei Phin / Hardacre, Jeffrey / Sauter, Patricia K / Kennedy, Eugene P / Yeo, Charles J / Rosato, Ernest L. ·Department of Surgery and the Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA. ·J Gastrointest Surg · Pubmed #22798186.

ABSTRACT: OBJECTIVE: The objective of the study was to assess the efficacy of two pancreatic remnant closure techniques following distal pancreatectomy: (1) stapled or sutured closure versus (2) stapled or sutured closure plus falciform patch and fibrin glue reinforcement in the setting of a prospective randomized trial, with the primary endpoint being pancreatic fistula. Pancreatic stump leak following left-sided pancreatic resection (distal pancreatectomy) remains common. Despite multiple and varied techniques for closure, the reported leak rate varies up to 30 %. A retrospective analysis by Iannitti et al. (J Am Coll Surg 203(6):857-864, 2006) detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue. METHODS: Between April 2008 and October 2011, all willing patients scheduled to undergo distal pancreatectomy at the authors' institutions were consented and enrolled at the preoperative office visit. Patients were intraoperatively stratified as having hard or soft glands and randomized to one of two groups: (1) closure utilizing stapling or suturing (SS) versus (2) stapled or sutured plus falciform ligament patch and fibrin glue (FF). The trial design and power analysis (α = 0.05, β = 0.2, power 80 %, chi-square test) hypothesized that the FF intervention would reduce the primary endpoint (pancreatic fistula) from 30 % to 15 % and targeted an accrual goal of 190 patients. Secondary endpoints included length of postoperative hospital stay, 30-day mortality, hospital readmission, and ISGPF fistula grade (A, B, and C). RESULTS: The trial accrued 109 patients, 55 in the SS group and 54 in the FF group. Enrollment was closed prior to the target accrual, following an interim analysis and futility calculation. Due to insufficient enrollment, patients stratified as having a hard gland were excluded (n = 8) from analysis, leaving 101 patients in the soft stratum. The overall pancreatic leak rate was 19.8 % (20 patients) for patients with soft glands. Patients randomized to the FF group had a leak rate of 20 %, as compared with 19.6 % in the SS group (p = 1.000). Fistula grades in both groups were identical: 1A, 8B, and 1C in the FF group as compared to 1A, 8B, and 1C in the SS group. Complication rates were comparable between the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group (28 % vs. 17.6 %, p = 0.243). CONCLUSION: The addition of a falciform ligament patch and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula in patients undergoing distal pancreatectomy (ClinicalTrials.gov NCT00889213).

17 Article Sarcoid-reaction mimicking metastatic malignant hepatopancreatobiliary tumors: report of two cases and review of the literature. 2012

Fong, Zhi Ven / Wong, Joshua / Maley, Warren R / Sandorfi, Nora / Winter, Jordan M / Koniaris, Leonidas G / Sauter, Patricia K / Yeo, Charles J / Lavu, Harish. ·Department of Surgery, Thomas Jefferson University, Jefferson Pancreas, Biliary and Related Cancer Center, Philadelphia, PA 19107, USA. ·J Gastrointest Surg · Pubmed #22258875.

ABSTRACT: INTRODUCTION: Sarcoidosis is a multisystem chronic granulomatous disease found predominantly in the lungs and lymph nodes. Its pathologic hallmark is the presence of systemic non-caseating granulomas; however, a variation of this disease known as "sarcoid-like reaction" has been described in patients with underlying cancer. REPORT: Sarcoid-like reactions in patients with hepatopancreatobiliary (HPB) tumors are rare findings, with only 15 cases having been reported in the English language literature. These reactions can be found in local lymph nodes or in distant organs, and when present in patients with cancer, they can mimic metastatic disease on imaging, potentially resulting in incorrect cancer staging and management. DISCUSSION: We describe two cases of patients with HPB tumors who had distant organ disease on cross-sectional imaging suspicious for metastases, which on further workup were found to be sarcoid-like reactions. We also discuss malignancy-induced sarcoid-like reactions and provide a review of the literature of sarcoid-like reactions in the setting of HPB tumors.

18 Minor Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: Is This Really a Short Learning Curve? 2016

Fong, Zhi Ven / Chang, David C / Ferrone, Cristina R / Lillemoe, Keith D / Fernandez Del Castillo, Carlos. ·Boston, MA. ·J Am Coll Surg · Pubmed #26809387.

ABSTRACT: -- No abstract --