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Biliary Tract Diseases

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Bile Duct Cancer

Patients who underwent pancreaticoduodenectomy for PDAC between 01/06/2010 and 31/05/2015

Patients who underwent pancreaticoduodenectomy for ampullary cancer between 01/06/2010 and 31/05/2015

Patients who underwent pancreaticoduodenectomy for distal extrahepatic cholangiocarcinoma between 01/06/2010 and 31/05/2015

Pancreaticoduodenectomy

Somaiah Aroori

Pancreatic head malignancies are aggressive cancers that are often inoperable when they are diagnosed. In the \~20% of patients who are diagnosed when the disease is still operable, surgery is the only treatment that can provide a chance of cure. Unfortunately, up to 75% of patients undergoing surgery will have the cancer come back (recur). One of the reasons for this is the challenge of removing the whole tumour with some surrounding non-cancerous tissue to ensure that every tumour cell has been removed. This is difficult because there are many structures very close to the pancreas (such as the blood vessels that supply the intestines) that cannot be removed. A recent review study of \>1700 patients who had a Whipple's operation (the cancer operation that is performed to remove the head of pancreas) and found that whilst the majority of patients had cancer recurrence in distant sites (like the liver) that would not be affected by how the operation was performed, 12% of patients had the cancer recur just at the site of where the operation had been; this is known as 'local' recurrence. This suggests that a small amount of cancer was not removed at the time of surgery in these patients. Very few studies have looked at the relationship between the Computerised Tomography (CT) scan before surgery and the histology results (information about the tumour after it has been examined under the microscope) and whether this can predict exactly where the tumour recurs. If investigators can find factors that predict which patients get local only recurrence, investigators may be able to offer improved surgical techniques or other therapies during or immediately after the operation to these patients, hopefully leading to improved cure rates.

This retrospective international study will look at these factors in patients who underwent a Whipple's operation for pancreatic cancer, bile duct cancer or ampullary cancer over a three year period between 2012 and 2015. Participating centres will provide data on pre-operative scans, complications around the time of surgery, any therapies (e.g. chemotherapy) that the patients had and if and where the cancer recurred. With this information, investigators hope to find ways to predict which patients will get local-only recurrence, so researchers can select them for future studies to see if additional treatments can improve the chance of cure from surgery for these patients.

Research window:

This retrospective observational cohort study will investigate the outcomes of patients who underwent pancreaticoduodenectomy at 30 hepatopancreaticobiliary (HPB) surgery centres in the UK and abroad between 01/06/2012 and 31/05/2015. These dates were chosen because:

* Most HPB units would expect to see 30-50 patients undergoing pancreaticoduodenectomy per annum. Based on the chief investigator's unit's prospectively maintained database of consecutive patients, 310 patients underwent pancreaticoduodenectomy during this window (benign and malignant). A five year research window would provide a large number of patients that is appropriate for subset analysis. This is especially important in distal cholangiocarcinoma, which is less commonly treated with pancreaticoduodenectomy compared to pancreatic and ampullary cancer. Even if all centres only provided 100 patients (20 per annum), this would provide a cohort of \~3000 patients. This number of cases will have greater resolution to detect small but significant statistical differences in studied variables.
* The amount of data available on patient records reduces with chronicity, in part due to a heavier reliance on paper rather than digital records. In addition, other reporting standards (e.g. TNM staging and histology reporting) change over time. 2010 was selected as a starting year as the 7th edition of the UICC TNM staging came into effect that year.
* An end date of June 2015 allows the study to collect full five-year follow up data on all patients to June 2020, thus providing a complete data set.

Data collection:

Data will be collected by each participating centre on a purpose-built REDCap database. REDCap is a well-established secure web-based data collection tool that is frequently used in medical research involving several centres. Advantages include:

* Real-time collection of data from all centres visible to the research team.
* Guaranteed anonymity of patients as only anonymised data will be collected.
* In-built data validation (e.g. set limits on expected ranges of values) to reduce poor quality/erroneous data collection.
* Easy download of data into a format suitable for processing on an appropriate statistical software package (e.g. SPSS).
* The ability to display or hide questions based on previous responses to tailor data collection to each record.

REDCap access is provided through University Hospitals Plymouth NHS Trust (UHPNT). Data is stored on the Microsoft Azure web-based cloud service. Servers are based in the EU and are GDPR compliant. REDCap access will be provided to all participating centres (one user log in per centre) for data collection.

Data collected falls into the following categories (examples given after each category are not exhaustive):

* Participant ID number (anonymised).
* Demographics: Age, sex, body mass index.
* Comorbidities: Diabetes, cardiovascular disease, respiratory disease, previous history of cancer.
* Pre-operative imaging: Dates, modalities, maximum tumour size, radiological TNM stage.
* Pre-operative biliary drainage: Approach, stent type.
* Neoadjuvant therapies: Type, duration.
* Pre-operative bilirubin.
* Surgery: Date, type, ASA grade, intraoperative procedures and findings.
* Post-operative complications: Types, date of occurrence, Clavien-Dindo grade, treatment, 30-day readmission, 90-day mortality and cause of death.
* Histology: Cancer type, differentiation, tumour size, pathological TNM stage, R status, involved margins and distance, total and involved number of resected lymph nodes, perineural, microvascular and named vessel invasion.
* Adjuvant therapies: Type, duration.
* Recurrence: Date of recurrence, site(s) of recurrence.
* Palliative therapies: Type, duration.
* Survival: Disease free survival (DFS) and overall survival (OS).

Screening of eligible patients:

Patients will be screened to ensure that they meet the inclusion and exclusion criteria (see below). Each unit will be responsible for screening patients for eligibility. All participating units have confirmed that they already have an existing list of consecutive patients who underwent PD during the research window. The clinical team at each participating unit will be responsible for maintaining a password-protected participant look up database that links the local patient hospital number to the anonymised participant ID number on REDCap.

Plymouth sub-study on sarcopenia and myosteatosis:

There is evidence that sarcopenia and myosteatosis may indicate a higher risk of postoperative complications, although its impact on DFS and OS is not yet established. Patients entered into the study from Plymouth will also have their pre-operative CT scan reviewed by a member of the research team trained in sarcopenia and myosteatosis estimation (an academic radiology trainee). The clinicians taking the measurements will be unaware of any outcomes or complications.

This is not being extended to other centres for the following reasons:

* Normal values of tissue attenuation are specific to local populations due to the variation in morphology of patients and the HU cut-offs in one country are not applicable to other countries. It would therefore not be possible to pool data on myosteatosis and sarcopenia from multiple countries.
* As the measurement relies on pre-operative CT imaging, and CT scanners and protocols vary between hospitals and change over time, it is difficult to retrospectively pool such data from multiple sites and maintain meaningful data. Using a single centre provides more robust data for analysis.
* The investigators will be using an inbuilt software package that is part of Plymouth's InSightWeb. This package may not be available in other centres.

As this reduces the number of patients in the cohort, Plymouth will extend its research window to 01/05/2006. This date was chosen as it is the beginning of their prospectively maintained database. This provides a pre-screened population of 365 patients who underwent PD at our unit, with a predicted 276 patients for analysis.

Recurrence After Whipple's (RAW) Study

An International Multi-centre Retrospective Cohort Study Investigating Patterns of Cancer Recurrence Following Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma, Ampullary Adenocarcinoma and Distal Bile Duct Cholangiocarcinoma

* The use of pre-operative endoscopic or percutaneous biliary stenting.
* Pre-operative systemic comorbidities.
* Pre-operative diagnosis of diabetes.
* Pre-operative radiological UICC Tumour Node Metastasis (TNM) staging.
* Named vessel involvement on pre-operative imaging.
* Sarcopenia or myosteatosis present on pre-operative imaging.\*
* The use of neoadjuvant chemotherapy/radiotherapy.
* Pre-operative serum bilirubin.
* Portal Vein (PV) / Superior Mesenteric Vein (SMV) resection.
* Hepatic Artery (HA) / Superior Mesenteric (SMA) / Coeliac Artery (CA) resection
* Need for peri-operative blood transfusion.
* Type of pancreatic anastomosis \[pancreatico-gastric (PG) vs. pancreatico-jejunal (PJ)\].
* Post-operative complications.
* The use and number of post-operative drains.
* Histological factors:
* The use of adjuvant chemotherapy.
* The use of palliative chemotherapy.

* Preoperative TNM staging.
* Named vessel involvement on preoperative imaging.
* The use of neoadjuvant chemotherapy/radiotherapy.
* PV/SMV resection.
* HA/SMA/CA resection.
* Histological factors
* The use of adjuvant chemotherapy.
* The use of palliative chemotherapy.

University of Plymouth

University Hospital Plymouth NHS Trust

Postoperative Complications

Fistula

Pancreatic Fistula

Gastrointestinal Agents

All Drugs and Chemicals

Pancrelipase

Pancreatin

The anti-mesenteric border of the jejunal loop proximal to the hepatico-jejunostomy is brought against the pancreatic stump. With the pancreatic stump retracted by the stay sutures, the transected end of pancreatic duct is first identified and secured by means of a blunt tipped probe. Each trans-pancreatic, suture was performed using a single Polydioxanone (PDS) 3 -0 blunt needle. We usually take 4 sutures, 2 on each side of the duct. The process is repeated in the same manner with the remaining sutures which are tightened at the end to approximate the jejunum loop to the stump. A small stab incision is then made at the anti-mesenteric border of the jejunum and a duct to mucosa anastomosis is constructed using an interrupted 5-0 Prolene. The process is completed by placing each of the retained needles through the seromuscular layer of the anterior jejunal wall and each knot is tied over the jejunal wall which is then warped over the cut end of the stump

Blumgart Anastomosis

It is a two layer, interrupted, end to side pancreatico-jejunostomy. First an interrupted sutures between the posterior capsule and the seromuscular layer of the jejunum was constructed using PDS 3-0 , then a duct to mucosa interrupted sutures were taken using PDS 5-0 and finally interrupted sutures between the anterior capsule and the jejunum . The main difference here is that the sutures are taken in a conventional way which is tangential to the pancreatic capsule and parenchyma

Cattell Warren Anastomosis

Ehab A Abdulmaksoud, Master

Haitham A Othman, MD

Ehab A Abdulmaksoud, master

The aim of this study is to make a step for evaluation and presentation of a safe technique for pancreatico-jejunostomy that help in minimizing post-operative morbidity and mortality in pancreatic cancer patient by comparing Blumgart anastomosis with Cattell warren technique of anastomosis.

Study Design This study is a randomized prospective clinical trial. Methods of randomization: Randomized block design

The objective of the study was to evaluate the effect of Blumgart anastomosis versus Cattell Warren techniques for pancreatico-jejunostomy regarding

* Surgical technique
* Peri-operative outcome including

  1. Length of hospital stay
  2. Post-operative pancreatic fistula
  3. ICU admission and stay
  4. Operative time
  5. Other morbidity and mortality

Data collection:

All data will be collected for each group and will be divided into Patients' factors, intraoperative and postoperative factors. Patients' factors include patients' demographics, co-morbidities, neoadjuvant treatment, Pathology and Biliary drainage. Intra-operative factors include type of Pancreaticoduodenectomy (PD) (Whether classic or PPPD), Operative time in hours and estimated blood loss in ml, pancreatic duct and texture of pancreas. Post-operative factors include the short term post-operative course which will be divided into specific complications (pancreatic leakage, biliary leakage, delayed gastric emptying, 2ry hemorrhage, intra-abdominal collection, deep wound infection, Portal Vein (PV) - Superior Mesenteric Vein (SMV) thrombosis and general surgical complications.

Pancreatico Enteric Anastomosis Post Pancreaticoduodenectomy

Comparison Between Blumgart Anastomosis and Cattell Warren Anastomosis in Reduction of Post-Operative Complications After Pancreaticoduodenectomy Procedure

We used the International Study Group of Pancreatic Fistula (ISGPF) definition which is any measurable pancreatic fluid output after postoperative day 3 (containing more than three times the normal serum amylase level; more than 300 IU/L) with clinical signs of an infection and/or necessitating a change in clinical management.

Any biliary output via percutaneous drains after the first postoperative day, or detected at a re-laparotomy

including early and late bleeding (1-3 weeks post-operative) According to ISGPF it is defined as any bleeding from the surgical site with a drop in hemoglobin concentration greater than 3 g/dL with peripheral circulatory impairment requiring medical, surgical, or radiological intervention.

Bleeding that occurs during or in the first day after the operation

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Recurrence After Whipple's (RAW) Study	NCT04596865	Pancreatic Canc... Ampullary Cance... Bile Duct Cance... Cholangiocarcin... Cholangiocarcin... Cholangiocarcin... Pancreatic Duct... Pancreatic Duct... Surgery Survivorship Recurrent Cance... Cancer Recurren... Cancer Recurren... Local Recurrenc...	Pancreaticoduod...	-	University Hospital Plymouth NHS Trust
Pancreatico Enteric Anastomosis Post Pancreaticoduodenectomy	NCT05163977	Cancer of Pancr...	Blumgart Anasto... Cattell Warren ...	-	Cairo University

Spots Global Cancer Trial Database for whipple's procedure