Are physical performance and frailty assessments useful in targeting and improving access to adjuvant therapy in patients undergoing resection for pancreatic cancer?

BACKGROUND: Many patients fail to receive adjuvant chemotherapy following pancreatic cancer surgery. This study implemented a multimodal, multidisciplinary approach to improving recovery after pancreatoduodenectomy (the 'Fast Recovery' programme) and measured its impact on adjuvant chemotherapy uptake and nutritional decline. The predictive accuracies of a bundle of frailty and physical performance assessments, with respect to the recipient of adjuvant chemotherapy, were also evaluated. RESULTS: The N = 44 patients treated after the introduction of the 'Fast Recovery' programme were not found to have a significantly higher adjuvant chemotherapy uptake than the N = 409 treated before the pathway change (80.5 vs. 74.3%, p = 0.452), but did have a significantly lower average weight loss at six weeks post-operatively (mean: 4.3 vs. 6.9 kg, p = 0.013). Of the pre-operative frailty and physical performance assessments tested, the 6-min walk test was found to be the strongest predictor of the receipt of adjuvant chemotherapy (area under the ROC curve: 0.91, p = 0.001); all patients achieving distances ≥ 360 m went on to receive adjuvant chemotherapy, compared to 33% of those walking < 360 m. CONCLUSIONS: The multimodal 'Fast Recovery' programme was not found to significantly improve access to adjuvant chemotherapy, but did appear to have benefits in reducing nutritional decline. Pre-operative assessments were found to be useful in identifying patients at risk of non-receipt of adjuvant therapies, with markers of physical performance appearing to be the best predictors. As such, these markers could be useful in targeting pre- and post-habilitation measures, such as physiotherapy and improved dietetic support.

Understanding pancreatic exocrine insufficiency and replacement therapy in pancreatic cancer.

Pancreatic exocrine insufficiency (PEI) is highly prevalent in patients with pancreatic cancer, and has substantial implications for quality of life and survival. Post resection, PEI is associated with increased post-operative complications, longer hospital stays and higher costs. Treatment with pancreatic enzyme replacement therapy (PERT) improves quality of life and confers significant survival advantages. Despite this many patients with pancreatic cancer do not currently receive PERT. The nutritional consequences of PEI are extensive and even more relevant in the elderly owing to age related gastrointestinal tract and pancreatic changes that predispose to malnutrition.

Clinical and patient reported outcomes in breast reconstruction using acellular dermal matrix.

INTRODUCTION: There is a lack of published patient reported outcome measures (PROMs) for the use of acellular dermal matrix (ADM) based breast reconstruction. This cohort study reviewed our clinical outcomes and PROMs. METHODS: All patients undergoing mastectomy with ADM assisted immediate breast reconstruction under a single surgeon between June 2013 and June 2017 were included. A prospectively kept database, clinic letters and operation notes were analysed. All patients received BREAST-QTM pre and post-operative questionnaires. RESULTS: Sixty-two consecutive patients with 77 reconstructions were included. Mean hospital stay was 3.3 days. All patients received 48 h of intravenous antibiotics, followed by a two-week course of oral antibiotics. Mean post-operative follow up was 17 months. There were 8 cases of skin necrosis (10.4%), and 1 infection (1.3%). These resulted in 4 explantations (5.2%); 3 following skin necrosis and 1 following infection. There was no observed 'red skin' syndrome. Post-operative mean score for 'satisfaction with outcome' was 83.1%. Mean score for 'Psychosocial well-being' was 70.7% and the mean score for 'physical well-being' was 77.9%. CONCLUSION: Our complication rates were comparable to those published, and PROMs were consistently good. The skin necrosis rate was potentially due to earlier practice of performing single-stage immediate reconstruction using fixed volume breast implants. We have modified our patient selection criteria and ADM based reconstructive techniques with experience. Longer term clinical and patient reported outcome should be sought.