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Pancreatic Neoplasms: HELP
Articles by Charles Mahlon Vollmer
Based on 37 articles published since 2010
(Why 37 articles?)
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Between 2010 and 2020, C. Vollmer wrote the following 37 articles about Pancreatic Neoplasms.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Guideline Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). 2014

Tol, Johanna A M G / Gouma, Dirk J / Bassi, Claudio / Dervenis, Christos / Montorsi, Marco / Adham, Mustapha / Andrén-Sandberg, Ake / Asbun, Horacio J / Bockhorn, Maximilian / Büchler, Markus W / Conlon, Kevin C / Fernández-Cruz, Laureano / Fingerhut, Abe / Friess, Helmut / Hartwig, Werner / Izbicki, Jakob R / Lillemoe, Keith D / Milicevic, Miroslav N / Neoptolemos, John P / Shrikhande, Shailesh V / Vollmer, Charles M / Yeo, Charles J / Charnley, Richard M / Anonymous3060801. ·Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. · Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: D.J.Gouma@amc.nl. · Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. · Department of First Surgery, Agia Olga Hospital, Athens, Greece. · Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. · Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France. · Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. · Department of General Surgery, Mayo Clinic, Jacksonville, FL. · Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. · Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. · Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. · Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. · First Department of Digestive Surgery, Hippokrateon Hospital, University of Athens, Athens, Greece; Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria. · Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. · Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA. · First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. · Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. · Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. · Department of Surgery, Penn Medicine, The University of Pennsylvania, Philadelphia, PA. · Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. · Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. ·Surgery · Pubmed #25061003.

ABSTRACT: BACKGROUND: The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy. METHODS: During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience. RESULTS: The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive. CONCLUSION: Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies.

2 Guideline Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). 2014

Hartwig, Werner / Vollmer, Charles M / Fingerhut, Abe / Yeo, Charles J / Neoptolemos, John P / Adham, Mustapha / Andrén-Sandberg, Ake / Asbun, Horacio J / Bassi, Claudio / Bockhorn, Max / Charnley, Richard / Conlon, Kevin C / Dervenis, Christos / Fernandez-Cruz, Laureano / Friess, Helmut / Gouma, Dirk J / Imrie, Clem W / Lillemoe, Keith D / Milićević, Miroslav N / Montorsi, Marco / Shrikhande, Shailesh V / Vashist, Yogesh K / Izbicki, Jakob R / Büchler, Markus W / Anonymous1650795. ·Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany. · Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. · Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France. · Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. · Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. · Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France. · Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. · Department of General Surgery, Mayo Clinic, Jacksonville, FL. · Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. · Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. · Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. · Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. · Department of First Surgery, Agia Olga Hospital, Athens, Greece. · Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. · Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. · Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. · Academic Unit of Surgery, University of Glasgow, Glasgow, UK. · Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. · First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. · Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. · Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. · Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. Electronic address: markus.buechler@med.uni-heidelberg.de. ·Surgery · Pubmed #24856668.

ABSTRACT: BACKGROUND: Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can involve adjacent organs, "extended" pancreatectomy that includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. RESULTS: Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit, and hospital morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared with standard resections but appears to be better compared with bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. CONCLUSION: Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established that are crucial for comparison of results of future trials across different practices and countries, in particular for those using neoadjuvant therapy.

3 Guideline Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). 2014

Bockhorn, Maximilian / Uzunoglu, Faik G / Adham, Mustapha / Imrie, Clem / Milicevic, Miroslav / Sandberg, Aken A / Asbun, Horacio J / Bassi, Claudio / Büchler, Markus / Charnley, Richard M / Conlon, Kevin / Cruz, Laureano Fernandez / Dervenis, Christos / Fingerhutt, Abe / Friess, Helmut / Gouma, Dirk J / Hartwig, Werner / Lillemoe, Keith D / Montorsi, Marco / Neoptolemos, John P / Shrikhande, Shailesh V / Takaori, Kyoichi / Traverso, William / Vashist, Yogesh K / Vollmer, Charles / Yeo, Charles J / Izbicki, Jakob R / Anonymous1640795. ·Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. · Department of HPB Surgery, Hôpital Edouard Herriot, Lyon, France. · Academic Unit of Surgery, University of Glasgow, Glasgow, UK. · First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. · Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. · Department of General Surgery, Mayo Clinic, Jacksonville, FL. · Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. · Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. · Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. · Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. · Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. · First Department of Surgery, Agia Olga Hospital, Athens, Greece. · Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France. · Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. · Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. · Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. · Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. · Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. · Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Centre, Mumbai, India. · Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. · St. Luke's Clinic - Center For Pancreatic and Liver Diseases, Boise, ID. · Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. · Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. · Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address: izbicki@uke.de. ·Surgery · Pubmed #24856119.

ABSTRACT: BACKGROUND: This position statement was developed to expedite a consensus on definition and treatment for borderline resectable pancreatic ductal adenocarcinoma (BRPC) that would have worldwide acceptability. METHODS: An international panel of pancreatic surgeons from well-established, high-volume centers collaborated on a literature review and development of consensus on issues related to borderline resectable pancreatic cancer. RESULTS: The International Study Group of Pancreatic Surgery (ISGPS) supports the National Comprehensive Cancer Network criteria for the definition of BRPC. Current evidence supports operative exploration and resection in the case of involvement of the mesentericoportal venous axis; in addition, a new classification of extrahepatic mesentericoportal venous resections is proposed by the ISGPS. Suspicion of arterial involvement should lead to exploration to confirm the imaging-based findings. Formal arterial resections are not recommended; however, in exceptional circumstances, individual therapeutic approaches may be evaluated under experimental protocols. The ISGPS endorses the recommendations for specimen examination and the definition of an R1 resection (tumor within 1 mm from the margin) used by the British Royal College of Pathologists. Standard preoperative diagnostics for BRPC may include: (1) serum levels of CA19-9, because CA19-9 levels predict survival in large retrospective series; and also (2) the modified Glasgow Prognostic Score and the neutrophil/lymphocyte ratio because of the prognostic relevance of the systemic inflammatory response. Various regimens of neoadjuvant therapy are recommended only in the setting of prospective trials at high-volume centers. CONCLUSION: Current evidence justifies portomesenteric venous resection in patients with BRPC. Basic definitions were identified, that are currently lacking but that are needed to obtain further evidence and improvement for this important patient subgroup. A consensus for each topic is given.

4 Review Recent Advances in Pancreatic Cancer Surgery. 2017

Maggino, Laura / Vollmer, Charles M. ·Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA. · Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. · Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA. Charles.Vollmer@uphs.upenn.edu. ·Curr Treat Options Gastroenterol · Pubmed #28852967.

ABSTRACT: OPINION STATEMENT: Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.

5 Review Definition and classification of chyle leak after pancreatic operation: A consensus statement by the International Study Group on Pancreatic Surgery. 2017

Besselink, Marc G / van Rijssen, L Bengt / Bassi, Claudio / Dervenis, Christos / Montorsi, Marco / Adham, Mustapha / Asbun, Horacio J / Bockhorn, Maximillian / Strobel, Oliver / Büchler, Markus W / Busch, Olivier R / Charnley, Richard M / Conlon, Kevin C / Fernández-Cruz, Laureano / Fingerhut, Abe / Friess, Helmut / Izbicki, Jakob R / Lillemoe, Keith D / Neoptolemos, John P / Sarr, Michael G / Shrikhande, Shailesh V / Sitarz, Robert / Vollmer, Charles M / Yeo, Charles J / Hartwig, Werner / Wolfgang, Christopher L / Gouma, Dirk J / Anonymous1010883. ·Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: m.g.besselink@amc.nl. · Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. · Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. · Department of First Surgery, Agia Olga Hospital, Athens, Greece. · Department of Surgery, Humanitas Research Hospital and University, Milan, Italy. · Department of HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France. · Department of Surgery, Mayo Clinic, Jacksonville, FL. · Department of General-, Visceral-, and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. · Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. · Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. · Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. · Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. · First Department of Digestive Surgery, Hippokrateon Hospital, University of Athens, Athens, Greece; Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria. · Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany. · Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA. · Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK. · Division of Subspecialty General Surgery, Mayo Clinic, Rochester, MN. · Department of GI and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. · Department of Surgical Oncology, Medical University in Lublin, Poland. · Department of Surgery, Penn Medicine, The University of Pennsylvania, Philadelphia, PA. · Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. · Division of Pancreatic Surgery, Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians University, University of Munich, Germany. · Department of Surgery, Johns Hopkins Medicine, Baltimore, MD. ·Surgery · Pubmed #27692778.

ABSTRACT: BACKGROUND: Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No international consensus definition or grading system of chyle leak currently is available. METHODS: The International Study Group on Pancreatic Surgery, an international panel of pancreatic surgeons working in well-known, high-volume centers, reviewed the literature and worked together to establish a consensus on the definition and classification of chyle leak after pancreatic operation. RESULTS: Chyle leak was defined as output of milky-colored fluid from a drain, drain site, or wound on or after postoperative day 3, with a triglyceride content ≥110 mg/dL (≥1.2 mmol/L). Three different grades of severity were defined according to the management needed: grade A, no specific intervention other than oral dietary restrictions; grade B, prolongation of hospital stay, nasoenteral nutrition with dietary restriction, total parenteral nutrition, octreotide, maintenance of surgical drains, or placement of new percutaneous drains; and grade C, need for other more invasive in-hospital treatment, intensive care unit admission, or mortality. CONCLUSION: This classification and grading system for chyle leak after pancreatic resection allows for comparison of outcomes between series. As with the other the International Study Group on Pancreatic Surgery consensus statements, this classification should facilitate communication and evaluation of different approaches to the prevention and treatment of this complication.

6 Review Laparoscopic versus open distal pancreatectomy for pancreatic cancer. 2016

Riviere, Deniece / Gurusamy, Kurinchi Selvan / Kooby, David A / Vollmer, Charles M / Besselink, Marc G H / Davidson, Brian R / van Laarhoven, Cornelis J H M. ·Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands. ·Cochrane Database Syst Rev · Pubmed #27043078.

ABSTRACT: BACKGROUND: Surgical resection is currently the only treatment with the potential for long-term survival and cure of pancreatic cancer. Surgical resection is provided as distal pancreatectomy for cancers of the body and tail of the pancreas. It can be performed by laparoscopic or open surgery. In operations on other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay as compared with open surgery. However, concerns remain about the safety of laparoscopic distal pancreatectomy compared with open distal pancreatectomy in terms of postoperative complications and oncological clearance. OBJECTIVES: To assess the benefits and harms of laparoscopic distal pancreatectomy versus open distal pancreatectomy for people undergoing distal pancreatectomy for pancreatic ductal adenocarcinoma of the body or tail of the pancreas, or both. SEARCH METHODS: We used search strategies to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and trials registers until June 2015 to identify randomised controlled trials (RCTs) and non-randomised studies. We also searched the reference lists of included trials to identify additional studies. SELECTION CRITERIA: We considered for inclusion in the review RCTs and non-randomised studies comparing laparoscopic versus open distal pancreatectomy in patients with resectable pancreatic cancer, irrespective of language, blinding or publication status.. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials and independently extracted data. We calculated odds ratios (ORs), mean differences (MDs) or hazard ratios (HRs) along with 95% confidence intervals (CIs) using both fixed-effect and random-effects models with RevMan 5 on the basis of intention-to-treat analysis when possible. MAIN RESULTS: We found no RCTs on this topic. We included in this review 12 non-randomised studies that compared laparoscopic versus open distal pancreatectomy (1576 participants: 394 underwent laparoscopic distal pancreatectomy and 1182 underwent open distal pancreatectomy); 11 studies (1506 participants: 353 undergoing laparoscopic distal pancreatectomy and 1153 undergoing open distal pancreatectomy) provided information for one or more outcomes. All of these studies were retrospective cohort-like studies or case-control studies. Most were at unclear or high risk of bias, and the overall quality of evidence was very low for all reported outcomes.Differences in short-term mortality (laparoscopic group: 1/329 (adjusted proportion based on meta-analysis estimate: 0.5%) vs open group: 11/1122 (1%); OR 0.48, 95% CI 0.11 to 2.17; 1451 participants; nine studies; I(2) = 0%), long-term mortality (HR 0.96, 95% CI 0.82 to 1.12; 277 participants; three studies; I(2) = 0%), proportion of people with serious adverse events (laparoscopic group: 7/89 (adjusted proportion: 8.8%) vs open group: 6/117 (5.1%); OR 1.79, 95% CI 0.53 to 6.06; 206 participants; three studies; I(2) = 0%), proportion of people with a clinically significant pancreatic fistula (laparoscopic group: 9/109 (adjusted proportion: 7.7%) vs open group: 9/137 (6.6%); OR 1.19, 95% CI 0.47 to 3.02; 246 participants; four studies; I(2) = 61%) were imprecise. Differences in recurrence at maximal follow-up (laparoscopic group: 37/81 (adjusted proportion based on meta-analysis estimate: 36.3%) vs open group: 59/103 (49.5%); OR 0.58, 95% CI 0.32 to 1.05; 184 participants; two studies; I(2) = 13%), adverse events of any severity (laparoscopic group: 33/109 (adjusted proportion: 31.7%) vs open group: 45/137 (32.8%); OR 0.95, 95% CI 0.54 to 1.66; 246 participants; four studies; I(2) = 18%) and proportion of participants with positive resection margins (laparoscopic group: 49/333 (adjusted proportion based on meta-analysis estimate: 14.3%) vs open group: 208/1133 (18.4%); OR 0.74, 95% CI 0.49 to 1.10; 1466 participants; 10 studies; I(2) = 6%) were also imprecise. Mean length of hospital stay was shorter by 2.43 days in the laparoscopic group than in the open group (MD -2.43 days, 95% CI -3.13 to -1.73; 1068 participants; five studies; I(2) = 0%). None of the included studies reported quality of life at any point in time, recurrence within six months, time to return to normal activity and time to return to work or blood transfusion requirements. AUTHORS' CONCLUSIONS: Currently, no randomised controlled trials have compared laparoscopic distal pancreatectomy versus open distal pancreatectomy for patients with pancreatic cancers. In observational studies, laparoscopic distal pancreatectomy has been associated with shorter hospital stay as compared with open distal pancreatectomy. Currently, no information is available to determine a causal association in the differences between laparoscopic versus open distal pancreatectomy. Observed differences may be a result of confounding due to laparoscopic operation on less extensive cancer and open surgery on more extensive cancer. In addition, differences in length of hospital stay are relevant only if laparoscopic and open surgery procedures are equivalent oncologically. This information is not available currently. Thus, randomised controlled trials are needed to compare laparoscopic distal pancreatectomy versus open distal pancreatectomy with at least two to three years of follow-up. Such studies should include patient-oriented outcomes such as short-term mortality and long-term mortality (at least two to three years); health-related quality of life; complications and the sequelae of complications; resection margins; measures of earlier postoperative recovery such as length of hospital stay, time to return to normal activity and time to return to work (in those who are employed); and recurrence of cancer.

7 Review Advances in Surgical Management of Pancreatic Diseases. 2016

Datta, Jashodeep / Vollmer, Charles M. ·Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address: Charles.Vollmer@uphs.upenn.edu. ·Gastroenterol Clin North Am · Pubmed #26895685.

ABSTRACT: The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.

8 Review Histological and Molecular Subclassification of Pancreatic and Nonpancreatic Periampullary Cancers: Implications for (Neo) Adjuvant Systemic Treatment. 2015

Erdmann, J I / Eskens, F A L M / Vollmer, C M / Kok, N F M / Groot Koerkamp, B / Biermann, K / van Eijck, C H J. ·Department of Surgery, Erasmus MC, Rotterdam, The Netherlands, j.i.erdmann@umcg.nl. ·Ann Surg Oncol · Pubmed #25503345.

ABSTRACT: The benefit of adjuvant chemotherapy for resected pancreatic ductal adenocarcinoma (PDAC) has been confirmed in randomized controlled trials. For nonpancreatic periampullary cancers (NPPC) originating from the distal bile duct, duodenum, ampulla, or papilla of Vater, the role of adjuvant therapy remains largely unclear. This review describes methods for distinguishing PDAC from NPPC by means of readily available and recently developed molecular diagnostic methods. The difficulties of reliably determining the exact origin of these cancers pathologically also is discussed. The review also considers the possibility of unintentional inclusion of NPPC in the most important adjuvant trials on PDAC and the subsequent implications for interpretation of the results. The authors conclude that correct determination of the origin of periampullary cancers is essential for clinical management and should therefore be systematically incorporated into clinical practice and future studies.

9 Review Investigational biomarkers for pancreatic adenocarcinoma: where do we stand? 2014

Datta, Jashodeep / Vollmer, Charles M. ·From the Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia. ·South Med J · Pubmed #24937521.

ABSTRACT: Although the outcomes for pancreatic ductal adenocarcinoma (PDAC) remain disappointing, there has been considerable improvement in the 5-year survival rate of patients with resectable disease. As such, an R0 surgical resection (microscopic tumor clearance) offers patients with PDAC the greatest survival benefit. Carbohydrate antigen 19-9, the only US Food and Drug Administration-approved biomarker for PDAC, is a poor screening tool and is most informative after PDAC resection. Consequently, there has been a tremendous initiative to discover novel biomarkers that may aid in detecting the disease earlier, improving prognosis, and predicting response to available chemotherapy. The number of implicated biomarkers in PDAC is indeed staggering, with >2500 proposed candidates presented in the recent literature. A vast majority of these biomarkers, however, remain in the investigational phase. This review categorizes the most promising biomarkers--those closest to potential clinical application--into diagnostic and prognostic/predictive groups. The greatest challenge likely lies in the search for an effective diagnostic biomarker that can accurately discriminate between malignant and benign disease, and thereby facilitate earlier identification of those patients with PDAC who may benefit most from surgical resection.

10 Review The economics of pancreas surgery. 2013

Vollmer, Charles M. ·Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, 3400 Spruce Street, 4th Floor, Silverstein Pavilion, Philadelphia, PA 19104, USA. Charles.Vollmer@uphs.upenn.edu ·Surg Clin North Am · Pubmed #23632154.

ABSTRACT: Pancreas surgery is a paradigm for high-acuity surgical specialization. Given the current intrigue over containing health care expenditures, pancreas surgery provides an ideal model to investigate the cost of care. This article explores the economics of this field from literature accrued over the last 2 decades. The cost of performing a pancreatic resection is established and then embellished with a discussion of the effects of clinical care paths. Then the influence of complications on costs is explored. Next, cost is investigated as an emerging outcome metric regarding variations in pancreatic surgical care. Finally, the societal-level fiscal impact is considered.

11 Review Risk scores and prognostic models in surgery: pancreas resection as a paradigm. 2012

Lewis, Russell S / Vollmer, Charles M. · ·Curr Probl Surg · Pubmed #23131540.

ABSTRACT: -- No abstract --

12 Clinical Trial Intraoperative Near-infrared Imaging Can Identify Neoplasms and Aid in Real-time Margin Assessment During Pancreatic Resection. 2019

Newton, Andrew D / Predina, Jarrod D / Shin, Michael H / Frenzel-Sulyok, Lydia G / Vollmer, Charles M / Drebin, Jeffrey A / Singhal, Sunil / Lee, Major K. ·Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. · Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY. ·Ann Surg · Pubmed #31188797.

ABSTRACT: OBJECTIVE: To determine if intraoperative near-infrared (NIR) imaging carries benefit in resection of pancreatic neoplasms. BACKGROUND: Resection of pancreatic malignancies is hindered by high rates of local and distant recurrence from positive margins and unrecognized metastases. Improved tumor visualization could improve outcomes. We hypothesized that intraoperative NIR imaging with a clinically approved optical contrast agent could serve as a useful adjunct in assessing margins and extent of disease during pancreatic resections. METHODS: Twenty patients were enrolled in an open-label clinical trial from July 2016 to May 2018. Subjects received second window indocyanine green (ICG) (2.5-5 mg/kg) 24 hours prior to pancreatic resection. NIR imaging was performed during staging laparoscopy and after pancreas mobilization in situ and following resection ex vivo. Tumor fluorescence was quantified using tumor-to-background ratio (TBR). Fluorescence at the specimen margin was compared to pathology evaluation. RESULTS: Procedures included 9 pancreaticoduodenectomies, 10 distal pancreatectomies, and 1 total pancreatectomy; 21 total specimens were obtained. Three out of 8 noninvasive tumors were fluorescent (mean TBR 2.59 ± 2.57). Twelve out of 13 invasive malignancies (n = 12 pancreatic adenocarcinoma, n = 1 cholangiocarcinoma) were fluorescent (mean TBR 4.42 ± 2.91). Fluorescence at the transection margin correlated with final pathologic assessment in 12 of 13 patients. Following neoadjuvant therapy, 4 of 5 tumors were fluorescent; these 4 tumors showed no treatment response on pathology assessment. One tumor had a significant treatment response and showed no fluorescence. CONCLUSIONS: Second window ICG reliably accumulates in invasive pancreatic malignancies and provides real-time feedback during pancreatectomy. NIR imaging may help to assess the response to neoadjuvant therapy.

13 Clinical Trial A phase I dose escalation trial of nab-paclitaxel and fixed dose radiation in patients with unresectable or borderline resectable pancreatic cancer. 2018

Shabason, Jacob E / Chen, Jerry / Apisarnthanarax, Smith / Damjanov, Nevena / Giantonio, Bruce / Loaiza-Bonilla, Arturo / O'Dwyer, Peter J / O'Hara, Mark / Reiss, Kim A / Teitelbaum, Ursina / Wissel, Paul / Drebin, Jeffrey A / Vollmer, Charles / Kochman, Michael / Mick, Rosemarie / Vergara, Norge / Jhala, Nirag / Doucette, Abigail / Lukens, John N / Plastaras, John P / Metz, James M / Ben-Josef, Edgar. ·Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA. jacob.shabason@uphs.upenn.edu. · Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, PCAM-2 West, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA. · Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA. · Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. · Department of Surgery, Memorial Sloane Kettering Cancer Center, New York, NY, USA. · Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. · Gastroenterology Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. · Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. · Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. · Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA. ·Cancer Chemother Pharmacol · Pubmed #29362902.

ABSTRACT: PURPOSE: Patients with locally advanced pancreatic cancer typically have poor outcomes, with a median survival of approximately 16 months. Novel methods to improve outcomes are needed. Nab-paclitaxel (Abraxane) has shown efficacy in pancreatic cancer and is FDA-approved for metastatic disease in combination with gemcitabine. Nab-paclitaxel is also a promising radiosensitizer based on laboratory studies, but it has never been clinically tested with definitive radiotherapy for locally advanced pancreatic carcinoma. METHODS: We performed a phase 1 study using a 3 + 3 dose escalation strategy to determine the safety and tolerability of dose-escalated nab-paclitaxel with fractionated radiotherapy for patients with unresectable or borderline resectable pancreatic cancer. Following induction chemotherapy with two cycles of nab-paclitaxel and gemcitabine, patients were treated with weekly nab-paclitaxel and daily radiotherapy to a dose of 52.5 Gy in 25 fractions. Final dose-limiting toxicity (DLT) determination was performed at day 65 after the start of radiotherapy. RESULTS: Nine patients received nab-paclitaxel at a dose level of either 100 mg/m CONCLUSIONS: The combination of fractionated radiation and weekly full dose nab-paclitaxel was safe and well-tolerated.

14 Article Postoperative narcotic use is associated with development of clinically relevant pancreatic fistulas after distal pancreatectomy. 2018

Kowalsky, Stacy J / Zenati, Mazen S / Dhir, Mashaal / Schaefer, Eric G / Dopsovic, Andrew / Lee, Kenneth K / Hogg, Melissa E / Zeh, Herbert J / Vollmer, Charles M / Zureikat, Amer H. ·Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA. · Division of Biostatistics, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA. · Pharmacy Department, University of Pittsburgh Medical Center, Pittsburgh, PA. · University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. · Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA. Electronic address: zureikatah@upmc.edu. ·Surgery · Pubmed #29269087.

ABSTRACT: BACKGROUND: Various strategies to decrease postoperative pancreatic fistula after a distal pancreatectomy have proved unsuccessful. Because narcotics can cause spasm of the sphincter of Oddi and thereby increase pressure within the pancreatic duct stump, we hypothesized that increased narcotic use would be associated with increased occurrence of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. METHODS: Retrospective analysis of consecutive distal pancreatectomies (2011-2016) was performed. Postoperative narcotic use was calculated in morphine equivalents. Postoperative pancreatic fistula was graded according to the International Study Group on Pancreatic Surgery. Perioperative variables were evaluated using multivariate logistic regression with clinically relevant postoperative pancreatic fistula as the dependent outcome. RESULTS: In the study, 310 distal pancreatectomies were analyzed (61% robotic, 20% open, 19% laparoscopic). Average age was 62 (53% female), and median total dose of morphine equivalents was 424 mg (interquartile range 242-768). Clinically relevant postoperative pancreatic fistula occurred in 21.6%. Clinically relevant postoperative pancreatic fistula and not clinically relevant postoperative pancreatic fistula cohorts were similar in most demographics and operative variables, but clinically relevant postoperative pancreatic fistula patients had fewer stapled transections (80 vs 90%, P=.025), less pancreatic cancers (11 vs 35%, P<.001), and greater median total morphine equivalents (577 vs 403 mg, P < .009). On univariate analysis, clinically relevant postoperative pancreatic fistula was associated with body mass index, nonstapled transection, suture ligation of the PD, a nonpancreatic cancer pathology, prophylactic octreotide, and total morphine equivalents >424 (cohort median). On multivariate analysis, only pancreatic cancer pathology was protective against a clinically relevant postoperative pancreatic fistula (odds ratio 0.24, confidence interval, 0.10-0.50, P=.001), while increasing total morphine equivalents were predictive of a clinically relevant postoperative pancreatic fistula (odds ratio 1.13, confidence interval, 1.01-1.27, P=.035) with a 13% increased risk for every approximate ≈100 mg increase in total morphine equivalents. CONCLUSION: In this retrospective analysis, postoperative narcotic use was associated with the development of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Limiting narcotic use may be one of the few available mitigating strategies against the development of a clinically relevant postoperative pancreatic fistula after distal pancreatectomy.

15 Article Decision-Making for the Management of Cystic Lesions of the Pancreas: How Satisfied Are Patients with Surgery? 2018

Puri, Priya M / Watkins, Ammara A / Kent, Tara S / Maggino, Laura / Jeganathan, Jenna Gates / Callery, Mark P / Drebin, Jeffrey A / Vollmer, Charles M. ·Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA. · Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. · Department of Surgery, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy. · Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA. Charles.Vollmer@uphs.upenn.edu. ·J Gastrointest Surg · Pubmed #28875275.

ABSTRACT: INTRODUCTION: This study aims to understand patients' perspectives and satisfaction with choosing surgery for the treatment of pancreatic cystic lesions (PCLs). METHODS: A 62-question survey was administered to 113 patients who had a resection for a PCL by 12 surgeons at two pancreatic specialty centers (2004-2016). Patients' final diagnoses and perioperative outcomes were correlated to the survey's results using univariate analysis. RESULTS: Fear of cancer was quite or extremely important in most respondents' decision to have surgery (95.4%). Respondents were quite or fully satisfied with the outcomes of surgery (91.1%) and with the decision-making process (89.3%). Distress from anxiety about the cyst before surgery (58.6%) largely outweighed that from postsurgical lifestyle changes (14.4%). Furthermore, 88.7% of patients with pathologically non-malignant disease were quite or fully satisfied with their decision to have surgery, and patients with mucinous neoplasms reported high satisfaction rates independent of grade of dysplasia or malignancy (p = 0.641). CONCLUSION: Patients with a resected PCL are highly satisfied with their decision to have surgery, regardless of the final diagnosis or clinical outcome. Fear of cancer is the main driver in the decision-making process, and the anxiety of harboring a cyst is a greater cause of distress than are postsurgical lifestyle changes.

16 Article Intraductal Papillary Mucinous Neoplasm Around the World: Are We Seeing Things the Same Way? 2017

Maggino, Laura / Vollmer, Charles M. ·Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy2Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia. · Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia. ·JAMA Surg · Pubmed #28122075.

ABSTRACT: -- No abstract --

17 Article Comparing American Gastroenterological Association Pancreatic Cyst Management Guidelines with Fukuoka Consensus Guidelines as Predictors of Advanced Neoplasia in Patients with Suspected Pancreatic Cystic Neoplasms. 2016

Ma, Gene K / Goldberg, David S / Thiruvengadam, Nikhil / Chandrasekhara, Vinay / Kochman, Michael L / Ginsberg, Gregory G / Vollmer, Charles M / Ahmad, Nuzhat A. ·Gastroenterology Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. · Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. · Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. · Gastroenterology Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Electronic address: nuzhat.ahmad@uphs.upenn.edu. ·J Am Coll Surg · Pubmed #27497827.

ABSTRACT: BACKGROUND: In 2015, the American Gastroenterological Association (AGA) published guidelines to provide recommendations for management of suspected pancreatic cystic neoplasms (PCNs). The aim of this study was to compare efficacy of these with the Fukuoka consensus guidelines in predicting advanced neoplasia (AN) in patients with suspected PCNs. STUDY DESIGN: We performed a retrospective study of 239 patients who underwent surgical resection for suspected mucinous PCN at a tertiary care center from 2000 to 2014. Surgical pathology was the gold standard. The AGA and Fukuoka criteria were applied, and their performance in predicting AN, defined as invasive cancer or high-grade dysplasia (HGD), was assessed. RESULTS: Advanced neoplasia was found in 71 of 239 (29.7%) patients (28 invasive cancer, 43 HGD). The Fukuoka "high-risk" (FG-HR) and AGA "high-risk" (AGA-HR) criteria identified patients with AN with sensitivities of 28.2% and 35.2%, specificities of 95.8% and 94.0%, positive predictive values of 74.1% and 71.4%, and negative predictive values of 75.9% and 77.5%, respectively. Overall, there was no significant difference between the guidelines for prediction of AN. There were 7 and 6 cases with invasive cancer, and 23 and 24 cases with HGD missed by the FG-HR and AGA-HR guidelines, respectively. CONCLUSIONS: In a retrospective analysis, the AGA guidelines are not superior to the Fukuoka guidelines in identifying AN in suspected PCNs. Both sets of guidelines have fair PPV for detection of AN, which would lead to avoidable resections in patients without AN. Additionally, the high-risk features of both guidelines do not accurately identify all patients with AN.

18 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.

19 Article The efficacy of adjuvant therapy for pancreatic invasive intraductal papillary mucinous neoplasm (IPMN). 2016

McMillan, Matthew T / Lewis, Russell S / Drebin, Jeffrey A / Teitelbaum, Ursina R / Lee, Major K / Roses, Robert E / Fraker, Douglas L / Vollmer, Charles M. ·Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. · Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. ·Cancer · Pubmed #26587698.

ABSTRACT: BACKGROUND: The literature investigating pancreatic invasive intraductal papillary mucinous neoplasm (IPMN) has largely come from small institutional studies, preventing adequately powered comparisons of adjuvant therapy versus surgery alone (SA) within specific patient subgroups. METHODS: Patients with resected, stage I through IV, invasive IPMN and conventional pancreatic ductal adenocarcinoma (PDAC) were identified in the National Cancer Data Base (1998-2010). Cox modeling of patients with invasive IPMN was used to compare overall survival (OS) between patients who received adjuvant therapy and those who underwent SA. A second model was used to compare OS between patients with invasive IPMN and those with PDAC. RESULTS: For the 1220 patients with invasive IPMN, the median OS was 28.9 months; the 1-year and 5-year actuarial survival rates were 76% and 17%, respectively; and 47% received adjuvant therapy. Cox modeling associated SA with worse OS (hazard ratio, 1.36; 95% confidence interval, 1.17-1.58; P = .00005) as well as American Joint Committee on Cancer (AJCC) TNM stage III/IV disease, positive lymph node status, positive margins, and poor tumor differentiation (all P ≤ .05). In addition, Cox modeling stratified by the following characteristics demonstrated improved OS with adjuvant therapy: AJCC TNM stage II or III/IV, positive lymph node status, positive margins, and poorly differentiated tumors. There was no survival advantage from adjuvant therapy for patients who had AJCC TNM stage I or lymph node-negative disease. Patients who had invasive IPMN had improved risk-adjusted OS compared with those who had PDAC (hazard ratio, 0.73; 95% confidence interval, 0.68-0.78; P < .00001). CONCLUSIONS: Invasive IPMN appears to be more indolent than conventional PDAC. Adjuvant therapy is associated with improved OS compared with SA in patients with invasive IPMN, especially for those with higher stage disease, positive lymph nodes, positive margins, or poorly differentiated tumors. Conversely, this benefit does not extend to patients with stage I or lymph node-negative disease.

20 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.

21 Article Laparoscopic versus open distal pancreatectomy: is a randomized trial necessary? 2015

Kooby, David A / Vollmer, Charles M. ·Department of Surgery, Emory University School of Medicine, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA. · Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. ·J Hepatobiliary Pancreat Sci · Pubmed #26150342.

ABSTRACT: -- No abstract --

22 Article Analysis of cyst size and tumor markers in the management of pancreatic cysts: support for the original Sendai criteria. 2015

Hoffman, Rebecca L / Gates, Jenna L / Kochman, Michael L / Ginsberg, Gregory G / Ahmad, Nuzhat A / Chandrasekhara, Vinay / Furth, Emma E / Vollmer, Charles M / Drebin, Jeffrey A. ·Department of Surgery, Hospital of the University of Pennsylvania Health System, Philadelphia, PA. Electronic address: Rebecca.hoffman@uphs.upenn.edu. · Department of Surgery, Hospital of the University of Pennsylvania Health System, Philadelphia, PA. · Department of Gastroenterology, Hospital of the University of Pennsylvania Health System, Philadelphia, PA. · Pathology and Laboratory Medicine, Anatomic Pathology Division, Hospital of the University of Pennsylvania Health System, Philadelphia, PA. ·J Am Coll Surg · Pubmed #25868415.

ABSTRACT: BACKGROUND: In 2006, the Sendai Consensus Guidelines identified size >3.0 cm as the only independent predictor of malignancy in incidentally discovered pancreatic cysts. The 2012 updated guidelines increased emphasis on radiographic features over size. Earlier studies included patients with preoperatively diagnosed carcinoma or with a corresponding mass. In this report, we characterize the use of size and serum tumor markers in the initial evaluation of pancreatic cystic neoplasms without preoperatively diagnosed adenocarcinoma and correlate them with clinical and pathologic outcomes. STUDY DESIGN: A retrospective cohort study was undertaken of 112 patients with a resected pancreatic cystic neoplasm. Patient demographics, cyst characteristics, preoperative serum tumor markers, morbidity, and mortality were captured. Statistical analysis included nonparametric tests of comparison, multivariate logistic regression, and receiver operating characteristic curve analyses. RESULTS: One hundred and twelve pancreatic cystic neoplasms were resected; there was one perioperative death. Mucinous cysts were common (78%), followed by serous cysts (13%). In total, 17% of cysts harbored malignancy. On multivariate analysis, the risk of malignancy in cysts≥3 cm was more than 4 times that of smaller cysts (relative risk (RR)=4.32; 95% CI, 1.55-12.07). There was no significant difference in serum CEA, cancer antigen 19-9, or cyst-fluid CEA levels between the benign and malignant groups. At a median follow-up of 30 months, the incidence of diabetes was 15%. CONCLUSIONS: Surgical resection of pancreatic cysts can be performed with low perioperative mortality and acceptable long-term morbidity. Use of cyst size as a rationale for resection of cystic lesion, as per the Sendai criteria, is justified.

23 Article Sendai and Fukuoka Consensus Guidelines Identify Advanced Neoplasia in Patients With Suspected Mucinous Cystic Neoplasms of the Pancreas. 2015

Kaimakliotis, Pavlos / Riff, Brian / Pourmand, Kamron / Chandrasekhara, Vinay / Furth, Emma E / Siegelman, Evan S / Drebin, Jeffery / Vollmer, Charles M / Kochman, Michael L / Ginsberg, Gregory G / Ahmad, Nuzhat A. ·Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. · Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. · Department of Surgical Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. · Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. · Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. · Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: Nuzhat.ahmad@uphs.upenn.edu. ·Clin Gastroenterol Hepatol · Pubmed #25818077.

ABSTRACT: BACKGROUND & AIMS: Little is known about whether the 2006 Sendai guidelines or 2012 Fukuoka guidelines are being used to determine the level of risk posed by suspected pancreatic mucinous cystic neoplasms (PCNs). We evaluated whether the guidelines accurately predicted which patients with suspected PCNs, which was based on cross-sectional imaging findings, would be found to have advanced neoplasia in surgery. METHODS: We performed a retrospective study of data collected from 194 patients with cystic lesions of the pancreas, which were assessed by cross-sectional imaging analyses, who underwent surgery for suspected PCNs at the Hospital at the University of Pennsylvania from 2000 through 2008. Imaging data were used to classify patients according to the Sendai guidelines as high risk or low risk and according to the Fukuoka guidelines as high risk, worrisome, or low risk. Pathology analyses of samples collected during surgery were used as the reference. A logistic regression model was created to identify factors associated with advanced neoplasia. The Sendai and Fukuoka guideline criteria were analyzed by univariate and multivariable logistic regression analyses. RESULTS: Advanced neoplasias were found in 36 patients (18.5%; 22 invasive cancers and 14 high-grade dysplasias). The median size of cysts was 33 mm. All patients found to have invasive cancers were accurately assigned to the Sendai guidelines high risk or Fukuoka guidelines high risk groups. However, 3 patients in the Sendai guidelines low risk and 2 patients in the Fukuoka guidelines low risk groups were found to have high-grade dysplasia. The Sendai guidelines identified patients with advanced neoplasia with 91.7% sensitivity, 21.5% specificity, 21% positive predictive value, and 91.9% negative predictive value. A designation of Fukuoka guidelines high risk identified patients with advanced neoplasia with 55.6% sensitivity, 73% specificity, 32% positive predictive value, and 87.9% negative predictive value. Overall, there was no statistically significant difference between the guidelines in predicting which patients had advanced neoplasia. On multivariate analysis, the presence of a mural nodule (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.33-6.27; P = .008), dilated main pancreatic duct >10 mm (OR, 7.44; 95% CI, 2.36-23.52; P = .001), or enhancing solid component (OR, 2.92; 95% CI, 1.16-7.64; P = .02) were associated with detection of advanced neoplasia in pancreatic cysts. CONCLUSION: On the basis of a retrospective analysis, the Sendai and Fukuoka guidelines accurately determine which patients with pancreatic cysts have advanced neoplasia. The guidelines accurately recommended surgical resection for all patients found to have invasive cancer, although some patients with high-grade dysplasia were missed. The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias. Cyst size was not associated with advanced neoplasia.

24 Article Structured reporting of multiphasic CT for pancreatic cancer: potential effect on staging and surgical planning. 2015

Brook, Olga R / Brook, Alexander / Vollmer, Charles M / Kent, Tara S / Sanchez, Norberto / Pedrosa, Ivan. ·From the Departments of Radiology (O.R.B., A.B.) and Surgery (T.S.K., N.S.), Beth Israel Deaconess Medical Center, Boston, Mass · Department of Surgery, University of Pennsylvania, Philadelphia, Pa (C.M.V.) · and Department of Radiology, University of Texas Southwestern Medical Center, 2201 Inwood Rd, 2nd Floor, Suite 202.Dallas, TX 75390-9085 (I.P.). ·Radiology · Pubmed #25286323.

ABSTRACT: PURPOSE: To compare structured versus nonstructured reporting of multiphasic computed tomography (CT) for staging of pancreatic cancer and the effects of both types of reporting on subjective assessment of resectability. MATERIALS AND METHODS: This institutional review board-approved, HIPAA-compliant retrospective study with waiver of informed consent included all patients who were referred for presurgical multiphasic CT of the pancreas between December 2006 and April 2011 at one institution before and after implementation (April 2008) of a structured reporting template. The template was created specifically for reporting multiphasic CT results to stage pancreatic cancer in patients and contained specific information relevant to surgical and oncologic planning. Multiphasic CT reports were assessed for the presence of 12 key features required for staging and surgical planning, including location, size, enhancement, node status, and vascular involvement. Three pancreatic surgeons evaluated the reports to assess resectability, surgical planning, and ease of extracting information before and after reviewing the multiphasic CT images blinded to the patient identifiers. The Student t test and χ(2) test were used for statistical analysis. RESULTS: Forty-eight (40%) structured and 72 (60%) nonstructured multiphasic CT reports were reviewed. Nonstructured reports contained a mean ± standard deviation of 7.3 key features ± 2.1 (range, 1-11) and structured reports contained 10.6 ± 0.9 (range, 9-12) features (P < .001). Information for surgical planning was deemed easily accessible in 94%, 60%, and 98% of structured and 47%, 54%, and 32% of nonstructured reports by the three surgeons, respectively (P < .001, .79, < .001). Surgeons had sufficient information for surgical planning in 96%, 69%, and 98% of structured and 31%, 43%, and 25% of nonstructured reports (P < .001, .009, and < .001). When surgeons reviewed reports in combination with multiphasic CT images, they were more likely to convert an answer of "unsure" regarding resectability to a definitive answer (ie, resectable or unresectable) when the reports were structured than when they were nonstructured. CONCLUSION: Structured reporting of pancreatic multiphasic CT provided superior evaluation of pancreatic cancer and facilitated surgical planning. Surgeons were more confident regarding decisions about tumor resectability when they reviewed structured reports before review of multiphasic CT images.

25 Article Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey. 2014

Hurdle, Valerie / Ouellet, Jean-Francois / Dixon, Elijah / Howard, Thomas J / Lillemoe, Keith D / Vollmer, Charles M / Sutherland, Francis R / Ball, Chad G. ·The Department of Surgery, University of Calgary, Calgary, Alta. · The Department of Surgery, Laval University, Quebec City, Que. · The Department of Surgery, Community Health Network, Indianapolis, Ind.. · The Department of Surgery, Harvard University, Massachusetts General Hospital, Boston, Mass. · The Department of Surgery, University of Pennsylvania, Philadelphia, PA. ·Can J Surg · Pubmed #24869619.

ABSTRACT: BACKGROUND: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS: We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION: Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

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