Impact of cholangitis on survival of patients with malignant biliary obstruction treated with percutaneous transhepatic biliary drainage.

PURPOSE: To evaluate the impact of cholangitis on survival of patients with gastrointestinal cancer and malignant biliary obstruction treated with percutaneous transhepatic biliary drainage (PTBD). METHODS: A retrospective registry study was performed at a tertiary center from 2000 to 2016 in Northern Finland. RESULTS: The study included 588 patients, 258 (43.9%) patients with pancreatic cancer, 222 (37.7%) with biliary tract cancer, and 108 (18.4%) with metastasis from gastrointestinal cancers. Patient mean age was 70 years, range 26 - 93 years. There were 288 [49.0%] women. The 30-day mortality rate was 30.8% for 156 patients with cholangitis before PTBD, 19.5% for 215 patients with cholangitis after PTBD and 25.8% for 217 patients without cholangitis (P = 0.039). The median survival was 1.8 months for patients with cholangitis before PTBD, 3.0 months for patients with cholangitis after PTBD, and 3.2 months for patients without cholangitis (P = 0.002). The hazard ratio (HR) for 1-year mortality for patients with cholangitis before PTBD was 1.3 (95% CI 1.06 - 1.67, P = 0.015) compared to patients with cholangitis after PTBD. After successful PTBD, 54 out of 291 patients received chemotherapy; the median survival was 5.2 months with cholangitis before PTBD, 9.4 months with cholangitis after PTBD and 15.3 months without cholangitis. CONCLUSION: In gastrointestinal cancers with malignant biliary obstruction, survival is poorer if cholangitis occurs before PTBD compared to cholangitis after PTBD. An oncologist's consultation is essential for assessing the possibility of chemotherapy in successfully treated PTBD patients, because of the notable survival benefit.

Evolution of pancreatic surgery over time and effects of centralization-a single-center retrospective cohort study.

Background: Short-term outcomes of pancreatic surgery have improved globally during the last two decades. Long-term survival of resectable pancreatic ductal adenocarcinoma (PDAC) has also shown slight improvement. We describe a cohort of 566 consecutive pancreatectomies performed at a Northern Finnish tertiary center. We analyze the trends in short-term outcomes of all-cause pancreatic surgery and long-term survival of PDAC patients. Methods: All pancreatic resections performed at the Oulu University Hospital during years 2000-2020 were included. Patient data was analyzed in four time periods (2000-2005, 2006-2010, 2011-2015 and 2016-2020). Clinicopathological parameters of patients and tumors, complication data and short-term mortality were recorded for all patients and compared between time quartiles. Long-term survival and administration rates of neo-, and/or adjuvant therapy of PDAC patients were analyzed. Results: A total of 566 pancreatectomies were performed during the study period: 359 (63%) pancreatoduodenectomies (PDs), 130 (23.0%) open left pancreatectomies (LPs), 45 (8.0%) laparoscopic LPs, 26 (5.1%) total pancreatectomies (TPs), and 6 (1.1%) enucleations. Median age of patients was 63 [57-71] years, and 49% [267] of patients were men. Number of pancreatectomies per time period increased from 67 in 2000-2005 to 266 in 2016-2020. American Society of Anesthesiologists (ASA) Physical Classification III patients and T3 tumors were more frequently operated on in later time periods. Complication rates remained at constant low levels throughout the study period, but reoperation rate increased from 9.4% in 2000-2010 to 16.2% in 2011-2020. Short-term (90-day) mortality after pancreatectomy decreased from 3.1% to 0.74%, while 5-year survival improved from 14.3% in 2006-2011 to 21.4% in 2011-2015. Resection rate of diagnosed PDAC cases, as reported by the Finnish Cancer Registry (FCR) for the catchment area, increased from 3.2% to 14.9% over the study period. Conclusions: The hospital volume of pancreatectomies has increased substantially, while complications and postoperative mortality have remained at acceptable levels. Long-term survival and resection rate of PDAC patients showed notable improvement over two decades.

Chemotherapy Improves Survival After Percutaneous Biliary Drainage in Patients With Pancreatic or Biliary Tract Cancer With Biliary Obstruction.

BACKGROUND: The survival benefit of chemotherapy compared to best supportive care (BSC) after percutaneous transhepatic biliary drainage (PTBD) was evaluated in patients with pancreatic or biliary tract cancer. PATIENTS AND METHODS: A retrospective registry study was conducted at a tertiary-level university hospital. The endpoint was survival measured from the PTBD and the initiation of chemotherapy. RESULTS: Among 158 patients (mean age=74 years, range=43-93 years; 51.9% women), 82 (51.9%) had pancreatic cancer and 76 (48.1%) had biliary tract cancer. After PTBD, 32 (20.3%) patients received chemotherapy and had a median survival of 11.7 months; 126 (79.7%) patients received only BSC resulting in a median survival of 1.7 months. The hazard ratio for survival at 1 year for patients who received chemotherapy compared to BSC was 0.22 (95% confidence interval=0.12-0.41, p<0.001). CONCLUSION: After PTBD, patients with pancreatic or biliary tract cancer should be critically evaluated by an oncologist to determine whether chemotherapy is possible, as it seems to significantly improve survival compared to BSC.

Treatment trends and outcomes of hepatocellular carcinoma in a single center for 35 years.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer mortality. The aim of this study was to examine the trends of HCC treatment and the outcomes in a single tertiary center for 35 years. METHODS: Two hundred seventy-three consecutive HCC patients between 1983-2018 were identified from Oulu University Hospital records. Primary outcomes of the study were postoperative complications within 30 days after the operation, and short- (30- and 90-day) and long-term (1, 3 and 5-year) survival. RESULTS: Of the 273 patients, 49 underwent surgical resection, 25 local ablation, 48 angiological treatment and 151 had palliative treatment. The rate of surgery declined over time, while other invasive treatments increased. Major complications occurred in 14 (28.6%) patients after surgical resection, in 2 (8.0%) patients after local ablation and in 13 (27.1%) patients after angiological treatment (P=0.022). Recurrence and local recidives were observed especially in local ablation group and in angiological treatment group (P<0.001). Overall survival rates in surgical resection group were at 30 and 90 days, 1-, 3- and 5-years 95.9%, 95.9%, 85.1%, 59.0% and 51.2%. In local ablation group, respective overall survival rates were 100.0%, 100.0%, 86.1%, 43.1% and 18.8%, and in angiological group 95.8%, 93.6%, 56.1%, 26.3% and 6.6%. In cox regression model adjusted for confounding factors, mortality hazard was lowest after surgical resection. Prognosis was poor in palliative group. CONCLUSIONS: Based on this Northern Finland population, the surgical resection of HCC has acceptable complication rate compared to other treatments; and yields the best long-term survival. Overall prognosis of HCC remains poor.

Is Palliative Percutaneous Drainage for Malignant Biliary Obstruction Useful?

BACKGROUND: Malignant biliary obstruction is a challenging problem for cancer patients. Here we evaluate predictive factors for survival following percutaneous drainage for malignant biliary obstruction in patients in whom endoscopic drainage was unsuccessful or insufficient. METHODS: A retrospective register study in a tertiary-level university hospital. RESULTS: A total of 643 cancer patients (317 females and 326 males) with malignant biliary obstruction were treated with percutaneous drainage at our hospital between 1999 and 2016. Their median overall survival rate was 2.6 months, with a 95% confidence interval (CI) of 2.2-3.0. Independent factors predicting poor outcome were metastatic cancer, with a hazard ratio (HR) of 2.2 (95% CI 1.8-2.7); Eastern Cooperative Oncology Group performance status (ECOG PS) of 2 (HR 2.3; 95% CI 1.8-2.8); ECOG PS of 3-4 (HR 3.5; 95% CI 2.8-4.4), American Society of Anesthesiologists physical status classification (ASA) of 4 (HR 2.1; 95% CI 1.5-2.9); and bilirubin of ≥60.0 µmol/L within 30 days post-drainage (HR 1.3; 95% CI 1.1-1.6). During the time periods 1999-2004 and 2005-2010, patients had poorer outcomes (HR 1.4; 95% CI 1.1-1.7 and HR 1.4; 95% CI 1.2-1.8) than during the last period 2011-2016. CONCLUSION: Patients with cancer who underwent percutaneous biliary drainage for biliary obstruction had a poor median overall survival. The usefulness of biliary drainage, especially in patients with metastatic cancer, poor ECOG PS, and high ASA class, should be critically considered.

Endoscopic transpapillary stenting for pancreatic fistulas after necrosectomy with necrotizing pancreatitis.

BACKGROUND: Data concerning the incidence and treatment of pancreatic fistula after necrosectomy in severe acute necrotizing pancreatitis (SAP) are scarce. Our aim was to assess the incidence of pancreatic fistula, and the feasibility and results of endoscopic transpapillary stenting (ETS) in patients with SAP after necrosectomy. METHODS: From January 2009 to December 2012 twenty-nine consecutive patients with SAP and necrosectomy in Oulu University Hospital were enrolled into this study. Five patients died before ETS because of the rapid progress of the disease and were, therefore, excluded. RESULTS: ERP was performed for the remaining 24 patients demonstrating fistula in 22/24 patients (92 %). ETS was successful in 23 patients and the fistula closed in all of them after a median of 82 (2-210) days with acceptable morbidity and no procedure-related mortality. CONCLUSION: All patients after necrosectomy for SAP seem to have internal or external pancreatic fistula. EST aimed at internal drainage of the necrosectomy cavity is a feasible and effective therapy in these patients.