胰臟癌切除可以提供緩解效果


  October 15, 2007(紐奧良) —加州大學洛杉磯分校(UCLA)退伍軍人醫院的新研究顯示,胰管十二指腸切除術(PD)對胰臟可切除或可手術移除的腺瘤有緩解治療效果。在美國,每年有37,000例胰臟癌,是癌症死亡的第四名;PD包括切除胰臟和十二指腸,僅適用10%的胰臟癌病患。研究作者UCLA手術結果與品質中心的外科住院醫師Irina Yermilov建議,雖然切除是唯一治療方式,但治癒率相當低— 約80%到90%的病患死亡。這些發現發表於美國外科醫學會第93屆臨床討論會。
  
  【研究者建立一個新的資料庫】
  雖然PD顯示有一些存活利益且較少再住院,但研究者希望知道,即使治癒率低,手術是否至少可以緩解胰臟癌症狀。研究在PD之後長期追蹤檢視再度住院的人數、時間和地區;再度住院的確定原因;以及辨識可以用來預測再度住院的病患因素。為了完成這些,研究團隊整合三個已知的資料庫建立一個新的資料庫:一個顯示在加州癌症註冊中心的所有病患,一個顯示所有住院病患檔案/該州非聯邦醫院所有可能之再度住院病例,另一個顯示該州所有的死亡個案(有可信的死亡率資料)。
  
  在29,523位病患中,1994到2004年間有1,802位病患因為胰臟癌進行PD,被納入此研究,使用「International Statistical Classification of Diseases and Related Health Problems, Ninth Edition (ICD-9) 」之PD編碼,全部都有完整的分期資訊;因為這是長期研究,全部病患中有6% (108)因為在30天內死亡而被排除。研究者辨識所有的再住院資料,直到病患死亡為止,檢查所有的 ICD-9 編碼,以確定再度住院之原因,使用單一變項和多變項回歸,以辨識任何可以用來預測再度住院的因素。
  
  研究對象的平均年齡是66歲,56%是淋巴結陽性,平均存活期間是17個月,存活者追蹤資訊期間最長達42.2個月。
  
  這1,802位病患中,19%在30天內,57%在1年內,以及74%在4年內再度住院;46%再度住院是到原先手術醫院以外的醫院— 資料庫中不一定可以追蹤到的事情,平均再度住院次數是2次;整體而言,PD之後有77.5%再度住院;22.5%不曾再度住院。
  
  末期胰臟癌病患中,70%到90%有胃腸道阻塞,30%到50%有膽管阻塞,80%到90%感受到腹痛;PD之後,研究中有39%病患因為脫水/營養不良,38%因為貧血,6%到16%因為GI阻塞,7%到12% 因為膽管阻塞,5% 到16%因為腹痛再度住院。
  
  研究並未發現可以預測再度住院的明顯病患因素。這77.5%的再度住院者中,56.4%是淋巴結陽性,平均住院天數為 18.2天;其他22.5%未曾再度住院者之中,55.7%是淋巴結陽性,平均住院天數為18.5 (整體P< .05);兩組中各類的腫瘤分期相似,兩性或病患種族之間沒有明顯差異。
  
  【研究的優缺點】
  Yermilov醫師引述該研究屬於強度大、高品質的住院病患和癌症註冊資料庫,準確捕捉加州的所有再度住院資料,並提供基本資料,可以提供基本訊息,她列出一些研究限制,如ICD-9紀錄不全以及缺乏準確的輔助治療資料。
  
  研究者結論認為,他們的發現提供更準確的PD後住院資訊,所觀察的緩解程度和之前發表的文獻相當。
  
  約翰霍普金斯外科助理教授,研究諮詢者Timothy Pawlik醫師表示,這是一個重要的議題;以再度住院來評估PD的緩解程度的敏感性有多少?病患未再度住院的理由可能千奇百怪都有,研究並沒有再度住院長度的詳細資料,例如住院期間的必要介入方式、這對稍早住院或一年後才住院的病患可能會有所不同。
  
  他進一步表示,我們估計手術期間的失血量?這或許可以作為手術困難度的標記。我認為有些嚴重缺點缺乏輔助資訊,例如,緩和只有有結果才有意義。什麼是我們要嘗試緩解的特定目標,緩解這些對改善生活品質的效果有多少?
  
  Yermilov 醫師回應表示,因為這是初步研究,我們無法檢視所有資料;舉例來說,我們沒有可以估計資料庫中血液損失量的方式,同樣的,沒有人像我們一樣探討再度住院,之前的研究顯示PD之後的再度住院率只有11%到 26%。
  
  Yermilov醫師和Pawlik醫師宣稱沒有相關財經關係。
  
  美國外科醫學會第93屆臨床討論會。手術論壇S11。發表於2007年10月8日。

Resection for Pancreatic Cance

By Lexa W Lee, ND
Medscape Medical News

October 15, 2007 (New Orleans) — Pancreaticoduodenectomy (PD) may have benefits as a palliative therapy in resectable or surgically removable adenocarcinoma of the pancreas, a new study at the University of California, Los Angeles (UCLA), Veterans Administration Hospital, suggests. There are 37,000 cases of pancreatic cancer in the United States per year; it is the fourth leading cause of cancer death. PD, which involves resecting the pancreas and duodenum, is possible in only 10% of pancreatic cancer patients. "While the only cure is resection, the cure rate is low — 80% to 90% of patients die," commented study author Irina Yermilov, MD, surgical resident at the UCLA Center for Surgical Outcomes and Quality. The findings were presented here at the American College of Surgeons 93rd Clinical Congress.

Researchers Created a New Database

Although PD has been shown to have some survival benefit with fewer readmissions, the researchers wanted to know whether the procedure could at least palliate symptoms of pancreatic cancer in view of the low cure rate. The study examined long-term follow-up after PD by examining the number, timing, and location of readmissions; determining reasons for readmissions; and identifying patient factors that may predict for readmission. To accomplish this, the research team created a new database by cross-linking 3 known databases: one that showed all patients with pancreatic cancer in the California Cancer Registry, another that showed all inpatient files/all possible readmissions to nonfederal hospitals in the state, and a third that showed all deaths in the state (for reliable mortality data).

Out of a total 29,523 patients, 1802 patients who had PD for pancreatic cancer from 1994 to 2004 were selected for the study, using International Statistical Classification of Diseases and Related Health Problems, Ninth Edition (ICD-9), codes for PD. All had complete staging information; as this was a long-term study, 6% of the patient total (108) with a mortality period of 30 days was excluded. The researchers identified all readmissions until death, examined all ICD-9 codes to determine reasons for readmission, and used univariate and multivariate regression to identify any factors that might predict for readmission.

The median age of the study group was 66 years, 56% were node-positive, median survival period was 17 months, and follow-up information for the survivors was available for 42.2 months.

Of the 1802 patients, 19% were readmitted within 30 days, 57% within a year, and 74% within 4 years. Forty-six percent were readmitted at a hospital other than where they were admitted for surgery — something that is not usually tracked in databases. The median number of readmissions was 2. Overall, 77.5% of the group was readmitted after PD; 22.5% were never readmitted.

Of patients suffering advanced pancreatic cancer, 70% to 90% have gastrointestinal obstruction, 30% to 50% have biliary obstruction, and 80% to 90% suffer abdominal pain. After PD, 39% patients in the study were readmitted for dehydration/malnutrition, 38% for anemia, 6% to 16% for GI obstruction, 7% to 12% for biliary obstruction, and 5% to 16% for abdominal pain.

No significant patient-level factors for predicting readmissions were found. Of the 77.5% readmitted, 56.4% were node-positive, with an 18.2-day mean length of stay; of the 22.5% never-readmitted group, 55.7% were node-positive, with an 18.5-day mean length of stay (P< .05, for all). Staging of tumors was similar at all levels between the 2 groups. There were no significant differences between genders or among races or patient ages.

Strengths and Shortcomings of Study

Dr. Yermilov cited the strengths of the study as the large, high-quality inpatient and cancer registry database, which accurately captures all hospital readmissions within California and provides baseline data, which can provide benchmark information. She listed some of the limitations of the study as ICD-9 undercoding and a lack of accurate adjuvant treatment data.

The researchers concluded that their findings provided a more accurate look at hospitalizations after PD and that palliation at the observed population levels agrees with previously published literature.

Timothy Pawlik, MD, assistant professor of surgery at Johns Hopkins and study discussant, said, "This is an important topic. How sensitive actually is readmission as a tool to evaluate how palliative PD is? There could be all sorts of reasons why a patient is not readmitted. The study didn't have details about length of stay for readmissions, such as interventions necessary during stay, [which] may be very different for patients admitted earlier on than maybe a year later."

He continued, "Was estimated blood loss at time of surgery looked at? It could be a surrogate marker for difficulty of case. I think there are some serious shortcomings with lack of adjuvant data [for example,] kind of treatment. Palliation only makes sense relative to an end. What specific end are we trying to palliate, and how effective are we palliating those things that affect quality of life?"

Dr. Yermilov responded, "Since this was a preliminary study, we couldn't look at all the data. We had no access to estimated blood loss in the database, for example. Still, no one has looked at readmissions in the way we have. Previous studies have only shown an 11% to 26% readmission rate after PD."

Dr. Yermilov and Dr. Pawlik have disclosed no relevant financial relationships.

American College of Surgeons 93rd Clinical Congress: Surgical Forum S11. Presented October 8, 2007.

    
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