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Pancreatic Neoplasms: HELP
Articles by Thomas J. Hugh
Based on 14 articles published since 2010
(Why 14 articles?)
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Between 2010 and 2020, T. Hugh wrote the following 14 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
1 Clinical Trial Distal pancreatectomy, splenectomy, and celiac axis resection (DPS-CAR): common hepatic arterial stump pressure should determine the need for arterial reconstruction. 2015

Mittal, Anubhav / de Reuver, Philip R / Shanbhag, Satya / Staerkle, Ralph F / Neale, Michael / Thoo, Catherine / Hugh, Thomas J / Gill, Anthony J / Samra, Jaswinder S. ·Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, Sydney, New South Wales, Australia. · Department of Surgery, University of Auckland, Auckland, New Zealand. · Department of Vascular Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, Sydney, New South Wales, Australia. · Department of Anatomical Pathology, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, Sydney, New South Wales, Australia. · Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, Sydney, New South Wales, Australia; Macquarie University Hospital, Macquarie University, Sydney, New South Wales, Australia. Electronic address: jas.samra@bigpond.com. ·Surgery · Pubmed #25532436.

ABSTRACT: BACKGROUND: Tumors arising in the neck and body of the pancreas often invade the common hepatic artery and celiac axis (CA), necessitating distal pancreatectomy, splenectomy, and celiac axis resection (DPS-CAR). In these patients, the need for revascularization of the common hepatic artery (CHA) can be avoided on the basis of the pressure change in the CHA after clamping of the CA. METHODS: All patients presenting to North Shore Hospital Campus of University of Sydney with advanced pancreatic malignancy of the neck and body between 2007 and 2014 were included in the study. The pressure in the CHA was measured pre- and postclamping of the CA; a decrease of more than 25% in the mean arterial pressure necessitated vascular reconstruction of the CHA. RESULTS: Seven patients underwent a DPS-CAR between 2007 and 2014. Arterial reconstruction was required in 2 patients based on a decrease of >25% mean arterial pressure in the CHA after clamping the CA. There was no in hospital or 90-day mortality, and no patients developed ischemic hepatitis. CONCLUSION: A single-stage DPS-CAR with selective arterial reconstruction based on the CHA pressure change after clamping the CA is a safe approach.

2 Article Pancreatoduodenectomy in a public versus private teaching hospital is comparable with some minor variations. 2018

Chua, Terence C / Mittal, Anubhav / Nahm, Chris / Hugh, Thomas J / Arena, Jenny / Gill, Anthony J / Samra, Jaswinder S. ·Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia. · Discipline of Surgery, The University of Sydney, Sydney, New South Wales, Australia. · Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Sydney, New South Wales, Australia. · The University of Sydney, Sydney, New South Wales, Australia. · Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia. · Macquarie University Hospital, Macquarie University, Sydney, New South Wales, Australia. ·ANZ J Surg · Pubmed #28982221.

ABSTRACT: BACKGROUND: The impact of the public and private hospital systems on major abdominal operations that are demanding on clinical resources, such as pancreatic surgery, has not been explored in an Australian setting. This study examines the perioperative outcome of patients undergoing pancreatoduodenectomy (PD) at a major public and private hospital. METHODS: Patients undergoing PD between January 2004 and October 2015 were classified based on their health insurance status and location of where the surgery was performed. Clinical variables relating to perioperative outcome were retrieved and compared using univariate and multivariate analyses. RESULTS: Four hundred and twenty patients underwent PD of whom 232 patients (55%) were operated on in the private hospital. Overall, there was no difference in morbidity and mortality in the public versus the private hospital. However, there were variations in public versus private hospital, this included longer duration of surgery (443 min versus 372 min; P < 0.001), increased estimated blood loss (683 mL versus 506 mL; P < 0.001) and more patients requiring perioperative blood transfusion (25% versus 13%; P = 0.001). Of the 10 complications compared, post-operative bleeding was higher in the private hospital (11% versus 5%; P = 0.051) and intra-abdominal collections were more common in the public hospital (11% versus 5%; P = 0.028). Independent predictive factors for major complications were American Society of Anesthesiologists score (odds ratio (OR) = 1.91; P = 0.050), patients requiring additional visceral resection (OR = 3.36; P = 0.014) and post-operative transfusion (OR = 3.37; P < 0.001). The hospital type (public/private) was not associated with perioperative outcome. CONCLUSION: Comparable perioperative outcomes were observed between patients undergoing PD in a high-volume specialized unit in both the public and private hospital systems.

3 Article Management of recurrent bleeding after pancreatoduodenectomy. 2018

Staerkle, Ralph F / Gundara, Justin S / Hugh, Thomas J / Maher, Richard / Steinfort, Brendan / Samra, Jaswinder S. ·Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, The University of Sydney, Sydney, New South Wales, Australia. · Department of Radiology, Royal North Shore Hospital, The University of Sydney, Sydney, New South Wales, Australia. ·ANZ J Surg · Pubmed #28480620.

ABSTRACT: BACKGROUND: Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-present danger and often presents diagnostic and management dilemmas. METHODS: All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were identified from a tertiary referral, clinical database (April 2004-April 2013). Only those suffering a second re-bleeding episode were included in the final case notes review. RESULTS: A total of 301 patients underwent pancreatoduodenectomy during the study period (most common indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional radiology and surgery were employed in each case. CONCLUSION: PPH presents major clinical challenges and is associated with significant morbidity and mortality. Early detection of the site and type of bleeding are critical and multimodal therapy is usually required. Interventional radiology techniques are making a major contribution to overall management.

4 Article Immunoregulatory Forkhead Box Protein p3-Positive Lymphocytes Are Associated with Overall Survival in Patients with Pancreatic Neuroendocrine Tumors. 2016

de Reuver, Philip R / Mehta, Shreya / Gill, Preetjote / Andrici, Juliana / D'Urso, Lisa / Clarkson, Adele / Mittal, Anubhav / Hugh, Thomas J / Samra, Jaswinder S / Gill, Anthony J. ·Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, New South Wales, Australia. Electronic address: Philipdereuver@gmail.com. · Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, New South Wales, Australia. · Department of Anatomical Pathology, Royal North Shore Hospital, Cancer Diagnosis and Pathology Group Kolling Institute of Medical Research, University of Sydney, New South Wales, Australia. · Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, New South Wales, Australia; Macquarie University Hospital, Macquarie University, New South Wales, Australia. ·J Am Coll Surg · Pubmed #26809747.

ABSTRACT: BACKGROUND: Forkhead box protein p3-positive (FoxP3(+)) regulatory T cells (Tregs) suppress host T-cell-mediated immune responses, limit surveillance against cancers, and have been associated with a poor prognosis. STUDY DESIGN: This study aims to identify the prognostic significance of FoxP3(+) Tregs in pancreatic neuroendocrine tumors (PNETs). Patients diagnosed with PNETs between 1992 and 2014 (n = 101) were included in this retrospective analysis. Clinical data, histopathology, and expression of FoxP3(+) Tregs and Ki-67 by immunohistochemistry were assessed. The association of these factors with survival was tested by log-rank test and in additional multivariable analysis. RESULTS: A total of 101 patients were included in this study. Mean age was 58.0 years (range 18 to 87 years) and median tumor size was 25 mm (range 8 to 160 mm). The degree of infiltration of tumor by FoxP3(+) Tregs was graded as 0 (n = 75), 1 (n = 15), or 2 (n = 11). Median follow-up was 50 months (interquartile range 123 months; Q1 = 20 months and Q3 = 123 months). In univariate analyses, patient age older than 57 years, TNM stage III or IV, tumor size >25 mm, Ki-67 labeling index >20, and a high number of FoxP3(+) tumor-infiltrating lymphocytes were significantly associated with poorer overall survival. In multivariable analyses, FoxP3(+) expression score of 2 (hazard ratio = 6.9; 95% CI 1.4-34.4) was the only statistically significant predictor for overall mortality. CONCLUSIONS: FoxP3(+) Treg expression is an independent prognostic factor in patients with PNETs, associated with statistically significant shorter overall survival. There is a role for additional research into the immune-mediated role of FoxP3(+) Tregs in PNETs.

5 Article A patient-derived subrenal capsule xenograft model can predict response to adjuvant therapy for cancers in the head of the pancreas. 2015

Xue, Aiqun / Julovi, Sohel M / Hugh, Thomas J / Samra, Jaswinder S / Wong, Matthew H F / Gill, Anthony J / Toon, Christopher W / Smith, Ross C. ·Cancer Surgery Group, Kolling Institute of Medical Research, The University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia. · Department of Gastrointestinal Surgery, Kolling Institute of Medical Research, The University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia. · Department of Pathology, Kolling Institute of Medical Research, The University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia. · Cancer Surgery Group, Kolling Institute of Medical Research, The University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia. Electronic address: ross.smith@sydney.edu.au. ·Pancreatology · Pubmed #26026767.

ABSTRACT: BACKGROUND: Although gemcitabine is commonly used as adjuvant therapy for pancreatic adenocarcinoma and pancreaticobiliary-type periampullary cancers, not all patients appear to benefit. This translational study evaluates the potential of a patient-derived subrenal capsule pancreatic cancer xenograft (SRCPCX) model to identify within eight weeks after surgery those tumours which will respond to gemcitabine. METHODS: SRCPCXs from 32 pancreatectomy patients were established in six to ten NOD/SCID mice per patient. After four weeks the mice were randomly assigned to receive gemcitabine or saline for four more weeks. After eight weeks, gemcitabine response in the grafts was evaluated by the percentage of tumour growth inhibition (%TGI), histological morphology and immunohistochemical markers (Ki-67, CK7 and cleaved caspase-3). These were collated into an Overall Response. Survival was assessed by Kaplan-Meier and Cox multivariate analyses. RESULTS: 375 of 450 pieces of tissue from 27 of 31 patients were evaluable. In 90% of patients, histopathological and immunostaining features of saline-treated control grafts were concordant with their original tumours. At follow up, six of 15 patients whose tumours had an Overall Response to gemcitabine died, compared with ten of 12 whose tumours did not respond (P = 0.025, Fisher's exact test). This was associated with improved survival on Kaplan-Meier analysis (P = 0.013). Cox multivariate analysis indicated that Overall Response, stage and grade were independent predictors of survival. CONCLUSION: This SRCPCX model retains major histopathological and immunohistochemical characteristics of the original tumour and when a combination of measures is used, enables early assessment of tumour sensitivity to gemcitabine in pancreatic cancers.

6 Article Cotargeting of epidermal growth factor receptor and PI3K overcomes PI3K-Akt oncogenic dependence in pancreatic ductal adenocarcinoma. 2014

Wong, Matthew H / Xue, Aiqun / Julovi, Sohel M / Pavlakis, Nick / Samra, Jaswinder S / Hugh, Thomas J / Gill, Anthony J / Peters, Lyndsay / Baxter, Robert C / Smith, Ross C. ·Cancer Surgery; Medical Oncology. · Cancer Surgery; · Medical Oncology. · Upper Gastrointestinal Surgery, and. · Pathology, Royal North Shore Hospital, Sydney, Australia. · Flow Cytometry Unit, Haematology Division; · Hormones and Cancer Division, Kolling Institute of Medical Research, University of Sydney; Departments of. · Cancer Surgery; Upper Gastrointestinal Surgery, and ross.smith@sydney.edu.au. ·Clin Cancer Res · Pubmed #24895459.

ABSTRACT: PURPOSE: PI3K-Akt is overexpressed in 50% to 70% of pancreatic ductal adenocarcinoma (PDAC). The hypothesis of this study is that PI3K and EGFR coinhibition may be effective in PDAC with upregulated PI3K-Akt signaling. EXPERIMENTAL DESIGN: Multiple inhibitors were tested on five PDAC cell lines. EGFR inhibitor (EGFRi)-resistant cell lines were found to have significantly overexpressed AKT2 gene, total Akt, and pAkt. In vitro erlotinib-resistant (ER) cell models (BxPC-ER and PANC-ER) with highly constitutively active PI3K-Akt were developed. These and their respective parent cell lines were tested for sensitivity to erlotinib, IGFIR inhibitor NVP-AEW541 (AEW), and PI3K-alpha inhibitor NVP-BYL719 (BYL), alone or in combination, by RTK-phosphoarray, Western blotting, immunofluorescence, qRT-PCR, cell proliferation, cell cycle, clonogenic, apoptosis, and migration assays. Erlotinib plus BYL was tested in vivo. RESULTS: Erlotinib acted synergistically with BYL in BxPC-ER (synergy index, SI = 1.71) and PANC-ER (SI = 1.44). Treatment of ER cell lines showing upregulated PI3K-Akt with erlotinib plus BYL caused significant G1 cell-cycle arrest (71%, P < 0.001; 58%, P = 0.003), inhibition of colony formation (69% and 72%, both P < 0.001), and necrosis and apoptosis (75% and 53%, both P < 0.001), more so compared with parent cell lines. In primary patient-derived tumor subrenal capsule (n = 90) and subcutaneous (n = 22) xenografts, erlotinib plus BYL significantly reduced tumor volume (P = 0.005). Strong pEGFR and pAkt immunostaining (2+/3+) was correlated with high and low responses, respectively, to both erlotinib and erlotinib plus BYL. CONCLUSION: PDAC with increased expression of the PI3K-Akt pathway was susceptible to PI3K-EGFR coinhibition, suggesting oncogenic dependence. Erlotinib plus BYL should be considered for a clinical study in PDAC; further evaluation of pEGFR and pAkt expression as potential positive and negative predictive biomarkers is warranted.

7 Article Frozen section of the pancreatic neck margin in pancreatoduodenectomy for pancreatic adenocarcinoma is of limited utility. 2014

Pang, Tony C Y / Wilson, Oliver / Argueta, Manuel A / Hugh, Thomas J / Chou, Angela / Samra, Jaswinder S / Gill, Anthony J. ·1Sydney Medical School, University of Sydney 2Department of Upper GIT Surgery, Royal North Shore Hospital, St Leonards 3Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, St Leonards 4Anatomical Pathology, Sydpath, St Vincent's Hospital, Darlinghurst 5Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia. ·Pathology · Pubmed #24614707.

ABSTRACT: The use of frozen section to assess resection margins intraoperatively during pancreaticoduodenectomy facilitates further resection. However, it is unclear whether this actually improves patient survival.We reviewed the overall survival and resection margin status in consecutive pancreaticoduodenectomies performed for carcinoma. An R1 resection was defined as an incomplete excision (≤1 mm margin); R0(p) resection as complete excision without re-resection and R0(s) resection as an initially positive neck margin which was converted to R0 resection after re-resection. Between 2007 and 2012, 116 pancreatoduodenectomies were performed for adenocarcinoma; 101 (87%) underwent frozen section of the neck margin which was positive in 19 (19%). Sixteen of these patients had negative neck margins after re-excision but only seven patients had no other involved margins [true R0(s) resections]. Median survival for the R0(p), R0(s) and R1 groups were 29, 16, 23 months, respectively (p = 0.049; R0(p) versus R0(s) p = 0.040). Intra-operative frozen section increased the overall R0 rate by 7% but this did not improve survival. Our findings question the clinical benefit of intraoperative margin assessment, particularly if re-excision cannot be performed easily and safely.

8 Article Adverse tumor biology associated with mesenterico-portal vein resection influences survival in patients with pancreatic ductal adenocarcinoma. 2014

Wang, F / Gill, A J / Neale, M / Puttaswamy, V / Gananadha, S / Pavlakis, N / Clarke, S / Hugh, T J / Samra, J S. ·Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private Hospital, University of Sydney, St Leonards, NSW, Australia, fwang1881@gmail.com. ·Ann Surg Oncol · Pubmed #24558067.

ABSTRACT: BACKGROUND: Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial. PATIENTS AND METHODS: Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD-VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed. RESULTS: Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD-VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD-VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD-VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival. CONCLUSIONS: PD with VR has similar morbidity but worse OS compared with a PD-VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.

9 Article The clinical impact of early complete pancreatic head devascularisation during pancreatoduodenectomy. 2013

Gundara, J S / Wang, F / Alvarado-Bachmann, R / Williams, N / Choi, J / Gananadha, S / Gill, A J / Hugh, T J / Samra, J S. ·Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Australia. ·Am J Surg · Pubmed #23809671.

ABSTRACT: BACKGROUND: Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes. METHODS: Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA-; n = 65) IPDA ligation groups. RESULTS: Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA-, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA-, 76% vs 65%; P = .426) or overall (P = .82) survival. CONCLUSIONS: Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.

10 Article Serum apolipoprotein C-II is prognostic for survival after pancreatic resection for adenocarcinoma. 2012

Xue, A / Chang, J W / Chung, L / Samra, J / Hugh, T / Gill, A / Butturini, G / Baxter, R C / Smith, R C. ·Department of Gastrointestinal Surgery, University of Sydney, Kolling Institute of Medical Research, St Leonards NSW 2065, Australia. ·Br J Cancer · Pubmed #23169340.

ABSTRACT: BACKGROUND: Pancreaticoduodenectomy remains a major undertaking. A preoperative blood test, which could confidently predict the benefits of surgery would improve the selection of pancreatic cancer patients for surgery. This study aimed to identify protein biomarkers prognostic for long-term survival and to validate them with clinico-pathological information. METHODS: Serum from 40 preoperative patients was used to train for predictive biomarkers using surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI), and the results were verified on 21 independent samples. Two predictive proteins were identified by tryptic peptide mass fingerprinting and sequencing, and validated on serum from another 57 patients by enzyme-linked immunosorbent assay (ELISA). The influence of these proteins on growth and invasion of two cancer cell lines was tested in-vitro. RESULTS: The SELDI panel of m/z 3700, 8222 and 11 522 peaks predicted <12 months' survival (ROC AUC: 0.79, 0.64-0.90; P<0.039). When CA19-9 was added, the ROC AUC increased to 0.95 (0.84-0.99; P<0.0001). The six subjects in the verification group who died within 12 months were correctly classified. The m/z 8222 and 11 522 proteins were identified as Serum ApoC-II and SAA-1, respectively. In the validation samples, ELISA results confirmed that ApoC-II was predictive of survival (Kaplan-Meier P<0.009), but not SAA-I. ApoC-II, CA19-9 and major-vessel involvement independently predicted survival. ApoC-II and SAA-1 increased cell growth and invasion of both cancer cell lines. CONCLUSION: Serum ApoC-II, CA19-9 and major-vessel invasion independently predict survival and improves selection of patients for pancreaticoduodenectomy.

11 Article Grafts for mesenterico-portal vein resections can be avoided during pancreatoduodenectomy. 2012

Wang, Frank / Arianayagam, Ranjan / Gill, Anthony / Puttaswamy, Vikram / Neale, Michael / Gananadha, Sivakumar / Hugh, Thomas J / Samra, Jaswinder S. ·Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards, New South Wales, Australia. ·J Am Coll Surg · Pubmed #22762991.

ABSTRACT: BACKGROUND: The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD+VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR). STUDY DESIGN: Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed. RESULTS: One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD+VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD+VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n = 101) required VR. A significantly higher rate of positive resection margins (p < 0.001) was noted in the PD+VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin. CONCLUSIONS: Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR.

12 Article Multivisceral resection of pancreatic neuroendocrine tumours: a report of two cases. 2011

Gundara, Justin S / Alvarado-Bachmann, Raul / Williams, Nicholas / Gananadha, Sivakumar / Gill, Anthony / Hugh, Thomas J / Samra, Jaswinder S. ·Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, St Leonards NSW 2065, Australia. ·World J Surg Oncol · Pubmed #21859472.

ABSTRACT: Pancreatic neuroendocrine tumours (pNETs) are rare and surgical resection offers the only possibility of cure for localised disease. The role of surgery in the setting of locally advanced and metastatic disease is more controversial. Emerging data suggests that synchronous surgical resection of pancreas and liver may be associated with increased survival. We report two cases of synchronous, one stage multivisceral resections for pNET and associated reconstruction. We highlight the technical issues involved in such extensive resections and demonstrate that one stage multivisceral operations can be achieved safely.

13 Article One hundred and seventy-eight consecutive pancreatoduodenectomies without mortality: role of the multidisciplinary approach. 2011

Samra, Jaswinder S / Bachmann, Raul Alvarado / Choi, Julian / Gill, Anthony / Neale, Michael / Puttaswamy, Vikram / Bell, Cameron / Norton, Ian / Cho, Sarah / Blome, Steven / Maher, Ritchie / Gananadha, Sivakumar / Hugh, Thomas J. ·Upper Gastrointestinal Surgical Unit, University of Sydney, Royal North Shore Hospital, St Leonards, NSW 2065, Sydney, Australia. jaswinder.samra@optusnet.com.au ·Hepatobiliary Pancreat Dis Int · Pubmed #21813392.

ABSTRACT: BACKGROUND: Pancreatoduodenectomy offers the only chance of cure for patients with periampullary cancers. This, however, is a major undertaking in most patients and is associated with a significant morbidity and mortality. A multidisciplinary approach to the workup and follow-up of patients undergoing pancreatoduodenectomy was initiated at our institution to improve the diagnosis, resection rate, mortality and morbidity. We undertook the study to assess the effect of this approach on diagnosis, resection rates and short-term outcomes such as morbidity and mortality. METHODS: A prospective database of patients presenting with periampullary cancers to a single surgeon between April 2004 and April 2010 was reviewed. All cases were discussed at a multidisciplinary meeting comprising surgeons, gastroenterologists, radiologists, oncologists, radiation oncologists, pathologists and nursing staff. A standardized investigation and management algorithm was followed. Complications were graded according to the Clavien-Dindo classification. RESULTS: A total of 295 patients with a periampullary lesion were discussed and 178 underwent pancreatoduodenectomy (resection rate 60%). Sixty-one patients (34%) required either a vascular or an additional organ resection. Eighty-nine patients experienced complications, of which the commonest was blood transfusion (12%). Thirty-four patients (19%) had major complications, i.e. grade 3 or above. There was no in-hospital, 30-day or 60-day mortality. CONCLUSIONS: Pancreatoduodenectomy can safely be performed in high-volume centers with very low mortality. The surgeon's role should be careful patient selection, intensive preoperative investigations, use of a team approach, and an unbiased discussion at a multidisciplinary meeting to optimize the outcome in these patients.

14 Article The infracolic approach to pancreatoduodenectomy for large pancreatic head tumours invading the colon. 2010

Alvarado-Bachmann, R / Choi, J / Gananadha, S / Hugh, T J / Samra, J S. ·Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of Sydney, St Leonards, NSW 2065, Australia. ·Eur J Surg Oncol · Pubmed #20843644.

ABSTRACT: BACKGROUND: Tumours arising from the head of the pancreas can invade both the proximal transverse colon and its mesocolon. At laparoscopy, this may be considered a contraindication to proceeding to pancreatoduodenectomy. However, in some patients, pancreatoduodenectomy can still be performed with an R0 resection using an en-bloc resection technique by an infracolic approach. METHODS: This technique relies on the infracolic control of the superior mesenteric vein (SMV) and is based on the presence of a normal fat cuff around the superior mesenteric artery (SMA) on pre-operative imaging. The dissection is maintained along the adventitial plane of the SMA. Pancreatoduodenectomy is performed in conjunction with en-bloc resection of the transverse colon. In the event of tumour invading the SMV, this is also resected en-bloc with the pancreatic head and transverse colon. We reviewed all such cases performed at our institution between April 2004 and April 2009. RESULTS: This technique was attempted in eleven patients. In two patients, the procedure had to be abandoned because of unexpected SMA encasement by tumour. In the remaining nine patients this procedure was carried out successfully. In this paper, the infracolic approach to pancreatoduodenectomy, and the associated limitations, are described in detail. CONCLUSION: The infracolic technique may be used to deal with large pancreatic head tumours and all pancreatic surgeons should be familiar with this technique. In the absence of metastatic disease, large pancreatic head tumours involving the colon can be resected en-bloc with the pancreatic head, as long as the SMA is not encased by the tumour.