Background:We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic.Methods: Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). Results:The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland. Conclusion:The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise. Contexte :Nous avons voulu clarifier le bien-fondé des interventions de prévention des fistules pancréatiques postopératoires (FPPO) après la pancréatectomie, car on déplore un manque de données cohérentes à ce sujet.Méthodes : Nous avons formé un comité d'experts qui a appliqué la méthode de consensus RAND/UCLA pour évaluer les scénarios cliniques d'interventions de prévention des FPPO après la pancréatoduodénectomie (PD) et la pancréatectomie distale, ou gauche (PG).Résultats : Les interventions suivantes ont été jugées appropriées : évaluation systématique du risque chez tous les patients; administration périopératoire de pasiréotide chez les patients soumis à une PD qui ont un pancréas mou et un canal pancréatique de moins de 3 mm de diamètre et chez les patients soumis à une PG; pancréatogastrostomie chez les patients soumis à une PD qui ont un pancréas mou et pancréatojéjunostomie chez les patients soumis à une PD dont le canal pancréatique mesure 6 mm ou plus de diamètre, indépendamment de la texture du pancréas; anastomose canal-muqueuse chez tous les patients soumis à une PD et anastomose en « dunking » chez les patients soumis à une PD qui ont un canal pancréatique de moins de 3 mm de diamètre et un pancréas fe...
3571 Background: Following primary chemoradiotherapy for squamous cell carcinoma of the anal canal (A-SCCa), 10% of patients have persistent cancer, and 30% develop local recurrence after initial complete response. Both persistent and recurrent A-SCCa may be amenable to salvage surgery, which typically involves intense health care resource utilization. Because only small cohorts have been reported, we synthesized the evidence for salvage surgery to gain a comprehensive understanding of outcomes. Methods: We systematically searched MEDLINE, Embase, and Cochrane Library (until October 11, 2018) for studies reporting on persistent or recurrent A-SCCa treated with salvage surgery. Quality assessment was performed using the Institute of Health Economics Quality Appraisal Checklist. Overall survival (OS) and disease-free survival (DFS) were pooled using two approaches: survival curve meta-analysis, and exact binomial likelihood random-effects model for survival probabilities. We used meta-regression, subgroup and sensitivity meta-analyses to explore sources of heterogeneity. Results: We identified 39 observational studies that included 1388 patients. Pooled 5-year OS was 45.5% (95% CI 40.6 to 49.9; 33 studies; 1308 patients), and did not differ in patients resected for recurrent (14 studies, n=259 patients) vs. persistent (n=238 patients) disease. There was no association of OS with study year, tumor size, or resection margin at the aggregate-level. Pooled 5-year DFS was 38.3% (95% CI 31.4-43.9; 14 studies; 554 patients). Pooled 30-day complications were 65.3% (95% CI 50.2-77.9; 17 studies; 720 patients): major complications 27.7% (95% CI 22.3-33.8), reoperations 12.7% (95% CI 8.7-18.2), and mortality 1.7% (95% CI 1.1-2.6%). Pooled perineal complications were 32.7% (95% CI 25.0-41.4). Conclusions: Salvage surgery offers 5-year OS of ≈45% and DFS of ≈40% for recurrent/persistent A-SCCa. Major complications and perineal wound complications are common, but postoperative mortality is rare. Presently, there are no reports of patient-reported outcomes such as quality of life after salvage surgery for A-SCCa. Comparative effectiveness studies comparing surgery to other treatments are warranted.
Background: While a large body of literature has addressed techniques and approaches to prevent POPF, available studies have often yielded conflicting results. There is lack of evidence-informed clinical guidelines and no accepted consensus on interventions to prevent POPF. We aimed to define the appropriateness of interventions for the prevention of POPF after pancreatectomy. Methods: Using RAND/UCLA appropriateness methods, a national expert panel of 13 hepato-pancreatico-biliary surgeons rated 161 clinical scenarios for interventions to prevent POPF after pancreatectomy. Scenarios were divided into risk prediction, somatostatin analogs, anastomosis for pancreaticoduodenectomy (PD), method of pancreatic transection for distal pancreatectomy (DP), topical surgical adjuncts, and surgical approach (minimally invasive vs. open). Scenarios were created for PD and DP and varied based on known risk factors for POPF, such as pancreatic duct size, gland texture, and intraoperative blood loss. Ratings ranged from 1 (highly inappropriate) to 9 (highly appropriate). An initial round of ratings was followed by an in-person meeting and subsequently a final round of ratings. Median scores from the final rating were used to categorize scenarios as appropriate (rating 1-3), uncertain (rating 4-6), or inappropriate (rating 7-9), and assess agreement among the panel. Results: Unless otherwise specified, there was agreement for all ratings. The following interventions were rated appropriate (26 scenarios): 1) individualized risk prediction for all pancreatectomies, 2) perioperative pasireotide for soft gland in DP and PD with duct 6mm regardless of gland texture, 4) duct-to-mucosa anastomosis for all PD and dunking anastomosis in PD for duct < 3mm with firm gland, 5) stapled transection for all DP and reinforced stapling for DP with soft gland, 6) surgical drains for PD and DP with soft gland, and 7) open and minimally invasive surgery for DP, and open surgery for PD. The following were rated inappropriate (5 scenarios): 1) gastrointestinal anastomosis for stump closure in all DP, 2) omission of surgical drain in PD for duct < 3mm with soft gland (indeterminate agreement). Use of the fistula risk score to direct perioperative management was rated uncertain. Topical agents were rated uncertain for all types of adjuncts and all scenarios for PD and DP. Conclusion: The expert panel has identified 26 appropriate and 5 inappropriate scenarios for the prevention of POPF following pancreatectomy, to provide guidance to clinicians, support standardization of practice and improve care received by patients. There was a high level of agreement
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