Pancreas • Volume 46, Number 9, October 2017
Letters to the Editor
REFERENCES 1. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386:85–96. 2. Aulinger BA, Bedorf A, Kutscherauer G, et al. Defining the role of GLP-1 in the enteroinsulinar axis in type 2 diabetes using DPP-4 inhibition and GLP-1 receptor blockade. Diabetes. 2014; 63:1079–1092. 3. Sato Y, Kamada T, Yamauchi A. The role of dipeptidyl peptidase 4 (DPP4) in the preservation of renal function: DPP4 involvement in hemoglobin expression. J Endocrinol. 2014;223: 133–142. 4. Jarmołowska B, Bielikowicz K, Iwan M, et al. Serum activity of dipeptidyl peptidase IV (DPPIV; EC 3.4.14.5) in breast-fed infants with symptoms of allergy. Peptides. 2007;28: 678–682. 5. Zhao H, Wei R, Wang L, et al. Activation of glucagon-like peptide-1 receptor inhibits growth and promotes apoptosis of human pancreatic cancer cells in a cAMP-dependent manner. Am J Physiol Endocrinol Metab. 2014;306: E1431–E1441. 6. Glorie LL, Verhulst A, Matheeussen V, et al. DPP4 inhibition improves functional outcome after renal ischemia-reperfusion injury. Am J Physiol Renal Physiol. 2012;303:F681–F688. 7. Mega C, Vala H, Rodrigues-Santos P, et al. Sitagliptin prevents aggravation of endocrine and exocrine pancreatic damage in the Zucker Diabetic Fatty rat—focus on amelioration of metabolic profile and tissue cytoprotective properties. Diabetol Metab Syndr. 2014;6:42. 8. Dobrian AD, Ma Q, Lindsay JW, et al. Dipeptidyl peptidase IV inhibitor sitagliptin reduces local inflammation in adipose tissue and in pancreatic islets of obese mice. Am J Physiol Endocrinol Metab. 2011;300: E410–E421. 9. Cieślińska A, Sienkiewicz-Szłapka E, Wasilewska J, et al. Influence of candidate polymorphisms on the dipeptidyl peptidase IV and μ-opioid receptor genes expression in aspect of the β-casomorphin-7 modulation functions in autism. Peptides. 2015;65:6–11.
Cumulative Radiation Exposure in Pancreatic Drainage Could it be Improved? To the Editor: ancreatic fluid collections (PFCs) are a complication that occurs in 42.7% of patients with acute pancreatitis, requiring image-guided percutaneous fluid
P
e72
www.pancreasjournal.com
TABLE 1. Imaging Modality Usage by Phase of Treatment for 101 Patients With 810 Imaging Studies for Pancreatic Fluid Collections Managed by Percutaneous Drainage Usage by Phase of Treatment (Mean, Total, Range) Modality
Diagnostic
Procedural
Follow-up
Computed tomography 1.52, 154, 1–8 0.26, 26, 0–3 2.63, 397, 0–18 Fluoroscopy 0, 0, 0 1.49, 150, 1–8* 0.62, 79, 0–5 Ultrasound (with fluoroscopy) 0, 0, 0 1.49, 150, 1–8* 0, 0, 0 Ultrasound (alone) 0.02, 2, 0–1 0, 0, 0 0.01, 2, 0–1
Total, Mean 577, 5.7 229, 2.3 150, 1.5 4, 0.04
*A combination of fluoroscopy and ultrasound was used for initial de novo access in 150 cases.
collection drainage (IGPD) as an accepted first-line treatment and multiple imaging studies for diagnosis, treatment, and follow-up.1–3 These patients have substantial radiation exposure from serial computed tomography (CT) imaging used to evaluate the fluid collections and drains. The purpose of our study was to evaluate serial imaging patterns of patients who underwent IGPD for acute pancreatitis-related PFCs. This study was an institutional review board–approved retrospective review of 101 patients (73 male, 28 female; mean age, 46.5 years; range, 3–81 years) who underwent IGPD of PFCs over a 9 year, 8 month period at a single institution. Patient inclusion criteria involved having one or more symptomatic acute pancreatitis fluid collection that was treated with IGPD. These patients underwent initial diagnostic CT imaging of the abdomen, procedural ultrasound (US) and fluoroscopy, and postprocedural follow-up CT imaging. Causes of pancreatitis were alcoholism (n = 41, 40.2%), trauma (n = 25, 24.5%), gallstones (n = 21, 20.6%), hypertriglyceridemia (n = 8, 7.8%), drugs (n = 1, 1%), and unknown (n = 6, 5.9%). Our institutional picture archive and retrieval system and patients' charts were reviewed for demographics, number of examinations by modality (CT, US, or fluoroscopy), phase of usage, and CT protocol. Imaging studies were categorized as diagnostic (predrainage), procedural (image guidance), and postdrainage follow up. Postdrainage (with drainage catheters in place) and follow-up imaging (with drainage catheters removed) was further subdivided. In patients with complete CT dosing reports, estimated effective dose was derived from dose-length product. The series included a total of 810 imaging studies, which are summarized in Table 1. There were a total of 478 (59%) follow-up imaging studies: 393 (48.5%) postdrainage studies (314 [79.9%] CTs and 79 [20.1%] fluoroscopies) and 85 (10.5%) follow-up studies (83 [97.6%] CT and 2 [2.4%] US). CT accounted for 71.2% of
all imaging in our 101 patients. The average CT per patient was 5.7. Of these, 68.8% were in the postdrainage follow-up phase (average 3.9 CT per patient). Most of the CT scans included the pelvis—348 (60.3%) in additional to the abdomen. There was unnecessary z-axis coverage (excessive anatomical scanning) and multiphase scans (to capture contrast phases) in 54 examinations (9.4%). Complete dosing reports for all follow-up CTs were available in 50 patients, and showed an average dose-length product of 3622.6716 mGy·cm and estimated effective dose of 54.34 mSv per patient Patients who underwent IGPD for PFCs had substantial exposure to imaging studies that used ionizing imaging in our series, with an average of 5.7 CT scans per patient. To reduce the cumulative radiation dose, one must delineate when CT is and is not required for diagnosis and treatment, especially during the postdrainage follow-up phase of treatment. CT is recommended for confirming clinical diagnosis, evaluating severity of disease, and reevaluating patients to ensure successful drainage and resolution.4 Alternatives to serial CT examinations include US, magnetic resonance imaging (MRI), or more judicious use of CT to limit z-axis coverage and limit multiphase scanning to those cases where imaging directly affects care. As an alternative to CT, both US and MRI have their limitations. On US, visualization of the pancreas may be limited by bowel gas, body habitus, or operator experience. Assessing the size and characteristics of an evolving peripancreatic fluid collection on US may be difficult as well. MRI certainly has the advantage of better delineation of the biliary system, however, it has long acquisition times and imaging peripancreatic collections in patients with indwelling drainage catheters may be difficult because of artifact caused by the catheters. Furthermore, some data has suggested that MRI may be more accurate than CT in predicting the severity and prognosis of acute pancreatitis.5 These principles can be implemented more
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Pancreas • Volume 46, Number 9, October 2017
effectively. Efforts should be made to shift the PFC/catheter monitoring form CT to MRI in the appropriate candidates. The post-PFC catheter placement, monitoring, and follow-up are the key stages where radiation exposure could be decreased. Our findings are similar to Ball et al.6 In their study of 238 patients with necrotizing pancreatitis requiring operative pancreatic or peripancreatic debridement, they retrospectively analyzed for CT-related radiation exposure. They found that only 20% of CT scans were followed by direct intervention, and commented that “The ubiquitous use of CT in necrotizing pancreatitis raises substantial public health concerns and mandates a careful reassessment of its utility.” Limitations of this study include its retrospective nature and data from a single center. Complete dosing reports were not available for all patients. Our findings are consistent with excessive ionizing imaging to patients with acute pancreatitis undergoing IGPD, especially during the follow-up period of care. Selective use of CT, especially in younger patients, is advisable and alternative imaging with MRI, and possibly US, should be used in appropriate situations. Follow-up MR examinations could have abbreviated protocols with limited sequences to answer the clinical question, especially if there is low suspicion for concurrent biliary processes. Such strategies will reduce radiation exposure for acute pancreatitis patients with symptomatic fluid collections requiring drainage. Dr D'Agostino has served as a paid speaker for Cook Medical. All other authors claim no potential conflicts of interest or disclosures relevant to this article. A preliminary version of this study was presented at the 2013 RSNA Annual Scientific Meeting as: Owens J, Caraway J, Gates M, Wallace D, Do D, D'Agostino H, Crow K. Pancreatic Drainage 101 Radiation Exposure: How Much and What Can We Do About It? Scientific Poster Presentation presented at: Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, Chicago, IL. Abstract available at: http://archive. rsna.org/2013/13012523.html. David H. Ballard, MD Mallinckrodt Institute of Radiology Washington University School of Medicine St Louis, MO [email protected]
Daniel V. Harper, BS School of Medicine Louisiana State University Health Shreveport Shreveport, LA
Letters to the Editor
Guillermo P. Sangster, MD Justin M. Owens, MD Horacio B. D'Agostino, MD Department of Radiology Louisiana State University Health Shreveport Shreveport, LA
PDAC. Therefore, a survey was undertaken among Dutch pancreatic surgeons to assess their current practice of follow-up and motivation to participate in new studies concerning the detection and treatment of isolated local recurrence of PDAC.
REFERENCES
MATERIALS AND METHODS
1. Cui ML, Kim KH, Kim HG, et al. Incidence, risk factors and clinical course of pancreatic fluid collections in acute pancreatitis. Dig Dis Sci. 2014;59:1055–1062.
All surgeon members of the Dutch Pancreatic Cancer Group were sent an online Web-based survey using SurveyMethods (www.surveymethods.com). The survey questions related to indications and contraindications for follow-up, diagnostic modalities used during follow-up, current follow-up frequency and methodology, and perceived primary and secondary goals of follow-up. Lastly, the opinion and feasibility for a new trial for patients with recurrence was sought.
2. Nesvaderani M, Eslick GD, Vagg D, et al. Epidemiology, aetiology and outcomes of acute pancreatitis: a retrospective cohort study. Int J Surg. 2015;23:68–74. 3. Ballard DH, Flanagan ST, Griffen FD. Percutaneous versus open surgical drainage: surgeon's perspective. J Am Coll Radiol. 2016;13:364. 4. D'Agostino HB, Hamidian Jahromi A, Jafarimehr E, et al. Strategy for effective percutaneous drainage of pancreatic collections: results on 121 patients. J La State Med Soc. 2013;165:74–81. 5. Kim YK, Kim CS, Han YM. Role of fat-suppressed T1-weighted magnetic resonance imaging in predicting severity and prognosis of acute pancreatitis: an intraindividual comparison with multidetector computed tomography. J Comput Assist Tomogr. 2009;33:651–656. 6. Ball CG, Correa-Gallego C, Howard TJ, et al. Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much? J Gastrointest Surg. 2010;14: 1529–1535.
Current Strategies for Detection and Treatment of Recurrence of Pancreatic Ductal Adenocarcinoma After Resection A Nationwide Survey To the Editor: ancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancerrelated mortality in Europe.1 Even after radical resection, around 75% of patients will experience disease recurrence.2 Detection and treatment of disease recurrence therefore offer a potential strategy to improve overall survival.3 Current Dutch guidelines for pancreatic cancer do not contain recommendations for follow-up frequency or strategy.4 Furthermore, they do not contain recommendations for the treatment of recurrent
P
RESULTS Thirty-nine surgeons from all 19 hospitals in the Netherlands that perform surgery for PDAC responded, resulting in a 81% response rate for active pancreatic surgeons. Four surgeons (10%) declared that they did not directly participate (anymore) in the follow-up of resected patients and only completed the second part of the survey. In Figure 1, results of survey questions that related to the methodology and philosophy of the current practice of follow-up are shown. Approximately 35% of surgeons advocated a less intensive follow-up strategy in case of low performance status due to advanced age or comorbidities. Table 1 shows the percentage of surgeons who adhered to a certain follow-up test at a specific moment. The most used follow-up strategy consisted of appointments at 3, 6, 12, 18, 24, 36, 48, and 60 months, with discharge from further follow-up after this period. After this period, appointments could be conducted by telephone. Different primary goals for followup were identified. Most surgeons (60%) regarded the primary goal to be supportive follow-up. More specifically, this included identifying and treating postoperative complications, monitoring pancreatic endocrine/exocrine insufficiency and nutritional status, patient guidance and reassurance, and guiding in end of life decision making. Seven other surgeons (20%) viewed the primary goal of follow-up to be based more on further therapeutical care, such as early detection and treatment of recurrence and planning of palliative treatment options. The remaining 20% named a combination of supportive and therapeutical goals. Nearly all surgeons (n = 37; 95%) were willing to participate in a new national
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.pancreasjournal.com
e73
Letters to the Editor
REFERENCES 1. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386:85–96. 2. Aulinger BA, Bedorf A, Kutscherauer G, et al. Defining the role of GLP-1 in the enteroinsulinar axis in type 2 diabetes using DPP-4 inhibition and GLP-1 receptor blockade. Diabetes. 2014; 63:1079–1092. 3. Sato Y, Kamada T, Yamauchi A. The role of dipeptidyl peptidase 4 (DPP4) in the preservation of renal function: DPP4 involvement in hemoglobin expression. J Endocrinol. 2014;223: 133–142. 4. Jarmołowska B, Bielikowicz K, Iwan M, et al. Serum activity of dipeptidyl peptidase IV (DPPIV; EC 3.4.14.5) in breast-fed infants with symptoms of allergy. Peptides. 2007;28: 678–682. 5. Zhao H, Wei R, Wang L, et al. Activation of glucagon-like peptide-1 receptor inhibits growth and promotes apoptosis of human pancreatic cancer cells in a cAMP-dependent manner. Am J Physiol Endocrinol Metab. 2014;306: E1431–E1441. 6. Glorie LL, Verhulst A, Matheeussen V, et al. DPP4 inhibition improves functional outcome after renal ischemia-reperfusion injury. Am J Physiol Renal Physiol. 2012;303:F681–F688. 7. Mega C, Vala H, Rodrigues-Santos P, et al. Sitagliptin prevents aggravation of endocrine and exocrine pancreatic damage in the Zucker Diabetic Fatty rat—focus on amelioration of metabolic profile and tissue cytoprotective properties. Diabetol Metab Syndr. 2014;6:42. 8. Dobrian AD, Ma Q, Lindsay JW, et al. Dipeptidyl peptidase IV inhibitor sitagliptin reduces local inflammation in adipose tissue and in pancreatic islets of obese mice. Am J Physiol Endocrinol Metab. 2011;300: E410–E421. 9. Cieślińska A, Sienkiewicz-Szłapka E, Wasilewska J, et al. Influence of candidate polymorphisms on the dipeptidyl peptidase IV and μ-opioid receptor genes expression in aspect of the β-casomorphin-7 modulation functions in autism. Peptides. 2015;65:6–11.
Cumulative Radiation Exposure in Pancreatic Drainage Could it be Improved? To the Editor: ancreatic fluid collections (PFCs) are a complication that occurs in 42.7% of patients with acute pancreatitis, requiring image-guided percutaneous fluid
P
e72
www.pancreasjournal.com
TABLE 1. Imaging Modality Usage by Phase of Treatment for 101 Patients With 810 Imaging Studies for Pancreatic Fluid Collections Managed by Percutaneous Drainage Usage by Phase of Treatment (Mean, Total, Range) Modality
Diagnostic
Procedural
Follow-up
Computed tomography 1.52, 154, 1–8 0.26, 26, 0–3 2.63, 397, 0–18 Fluoroscopy 0, 0, 0 1.49, 150, 1–8* 0.62, 79, 0–5 Ultrasound (with fluoroscopy) 0, 0, 0 1.49, 150, 1–8* 0, 0, 0 Ultrasound (alone) 0.02, 2, 0–1 0, 0, 0 0.01, 2, 0–1
Total, Mean 577, 5.7 229, 2.3 150, 1.5 4, 0.04
*A combination of fluoroscopy and ultrasound was used for initial de novo access in 150 cases.
collection drainage (IGPD) as an accepted first-line treatment and multiple imaging studies for diagnosis, treatment, and follow-up.1–3 These patients have substantial radiation exposure from serial computed tomography (CT) imaging used to evaluate the fluid collections and drains. The purpose of our study was to evaluate serial imaging patterns of patients who underwent IGPD for acute pancreatitis-related PFCs. This study was an institutional review board–approved retrospective review of 101 patients (73 male, 28 female; mean age, 46.5 years; range, 3–81 years) who underwent IGPD of PFCs over a 9 year, 8 month period at a single institution. Patient inclusion criteria involved having one or more symptomatic acute pancreatitis fluid collection that was treated with IGPD. These patients underwent initial diagnostic CT imaging of the abdomen, procedural ultrasound (US) and fluoroscopy, and postprocedural follow-up CT imaging. Causes of pancreatitis were alcoholism (n = 41, 40.2%), trauma (n = 25, 24.5%), gallstones (n = 21, 20.6%), hypertriglyceridemia (n = 8, 7.8%), drugs (n = 1, 1%), and unknown (n = 6, 5.9%). Our institutional picture archive and retrieval system and patients' charts were reviewed for demographics, number of examinations by modality (CT, US, or fluoroscopy), phase of usage, and CT protocol. Imaging studies were categorized as diagnostic (predrainage), procedural (image guidance), and postdrainage follow up. Postdrainage (with drainage catheters in place) and follow-up imaging (with drainage catheters removed) was further subdivided. In patients with complete CT dosing reports, estimated effective dose was derived from dose-length product. The series included a total of 810 imaging studies, which are summarized in Table 1. There were a total of 478 (59%) follow-up imaging studies: 393 (48.5%) postdrainage studies (314 [79.9%] CTs and 79 [20.1%] fluoroscopies) and 85 (10.5%) follow-up studies (83 [97.6%] CT and 2 [2.4%] US). CT accounted for 71.2% of
all imaging in our 101 patients. The average CT per patient was 5.7. Of these, 68.8% were in the postdrainage follow-up phase (average 3.9 CT per patient). Most of the CT scans included the pelvis—348 (60.3%) in additional to the abdomen. There was unnecessary z-axis coverage (excessive anatomical scanning) and multiphase scans (to capture contrast phases) in 54 examinations (9.4%). Complete dosing reports for all follow-up CTs were available in 50 patients, and showed an average dose-length product of 3622.6716 mGy·cm and estimated effective dose of 54.34 mSv per patient Patients who underwent IGPD for PFCs had substantial exposure to imaging studies that used ionizing imaging in our series, with an average of 5.7 CT scans per patient. To reduce the cumulative radiation dose, one must delineate when CT is and is not required for diagnosis and treatment, especially during the postdrainage follow-up phase of treatment. CT is recommended for confirming clinical diagnosis, evaluating severity of disease, and reevaluating patients to ensure successful drainage and resolution.4 Alternatives to serial CT examinations include US, magnetic resonance imaging (MRI), or more judicious use of CT to limit z-axis coverage and limit multiphase scanning to those cases where imaging directly affects care. As an alternative to CT, both US and MRI have their limitations. On US, visualization of the pancreas may be limited by bowel gas, body habitus, or operator experience. Assessing the size and characteristics of an evolving peripancreatic fluid collection on US may be difficult as well. MRI certainly has the advantage of better delineation of the biliary system, however, it has long acquisition times and imaging peripancreatic collections in patients with indwelling drainage catheters may be difficult because of artifact caused by the catheters. Furthermore, some data has suggested that MRI may be more accurate than CT in predicting the severity and prognosis of acute pancreatitis.5 These principles can be implemented more
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Pancreas • Volume 46, Number 9, October 2017
effectively. Efforts should be made to shift the PFC/catheter monitoring form CT to MRI in the appropriate candidates. The post-PFC catheter placement, monitoring, and follow-up are the key stages where radiation exposure could be decreased. Our findings are similar to Ball et al.6 In their study of 238 patients with necrotizing pancreatitis requiring operative pancreatic or peripancreatic debridement, they retrospectively analyzed for CT-related radiation exposure. They found that only 20% of CT scans were followed by direct intervention, and commented that “The ubiquitous use of CT in necrotizing pancreatitis raises substantial public health concerns and mandates a careful reassessment of its utility.” Limitations of this study include its retrospective nature and data from a single center. Complete dosing reports were not available for all patients. Our findings are consistent with excessive ionizing imaging to patients with acute pancreatitis undergoing IGPD, especially during the follow-up period of care. Selective use of CT, especially in younger patients, is advisable and alternative imaging with MRI, and possibly US, should be used in appropriate situations. Follow-up MR examinations could have abbreviated protocols with limited sequences to answer the clinical question, especially if there is low suspicion for concurrent biliary processes. Such strategies will reduce radiation exposure for acute pancreatitis patients with symptomatic fluid collections requiring drainage. Dr D'Agostino has served as a paid speaker for Cook Medical. All other authors claim no potential conflicts of interest or disclosures relevant to this article. A preliminary version of this study was presented at the 2013 RSNA Annual Scientific Meeting as: Owens J, Caraway J, Gates M, Wallace D, Do D, D'Agostino H, Crow K. Pancreatic Drainage 101 Radiation Exposure: How Much and What Can We Do About It? Scientific Poster Presentation presented at: Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, Chicago, IL. Abstract available at: http://archive. rsna.org/2013/13012523.html. David H. Ballard, MD Mallinckrodt Institute of Radiology Washington University School of Medicine St Louis, MO [email protected]
Daniel V. Harper, BS School of Medicine Louisiana State University Health Shreveport Shreveport, LA
Letters to the Editor
Guillermo P. Sangster, MD Justin M. Owens, MD Horacio B. D'Agostino, MD Department of Radiology Louisiana State University Health Shreveport Shreveport, LA
PDAC. Therefore, a survey was undertaken among Dutch pancreatic surgeons to assess their current practice of follow-up and motivation to participate in new studies concerning the detection and treatment of isolated local recurrence of PDAC.
REFERENCES
MATERIALS AND METHODS
1. Cui ML, Kim KH, Kim HG, et al. Incidence, risk factors and clinical course of pancreatic fluid collections in acute pancreatitis. Dig Dis Sci. 2014;59:1055–1062.
All surgeon members of the Dutch Pancreatic Cancer Group were sent an online Web-based survey using SurveyMethods (www.surveymethods.com). The survey questions related to indications and contraindications for follow-up, diagnostic modalities used during follow-up, current follow-up frequency and methodology, and perceived primary and secondary goals of follow-up. Lastly, the opinion and feasibility for a new trial for patients with recurrence was sought.
2. Nesvaderani M, Eslick GD, Vagg D, et al. Epidemiology, aetiology and outcomes of acute pancreatitis: a retrospective cohort study. Int J Surg. 2015;23:68–74. 3. Ballard DH, Flanagan ST, Griffen FD. Percutaneous versus open surgical drainage: surgeon's perspective. J Am Coll Radiol. 2016;13:364. 4. D'Agostino HB, Hamidian Jahromi A, Jafarimehr E, et al. Strategy for effective percutaneous drainage of pancreatic collections: results on 121 patients. J La State Med Soc. 2013;165:74–81. 5. Kim YK, Kim CS, Han YM. Role of fat-suppressed T1-weighted magnetic resonance imaging in predicting severity and prognosis of acute pancreatitis: an intraindividual comparison with multidetector computed tomography. J Comput Assist Tomogr. 2009;33:651–656. 6. Ball CG, Correa-Gallego C, Howard TJ, et al. Radiation dose from computed tomography in patients with necrotizing pancreatitis: how much is too much? J Gastrointest Surg. 2010;14: 1529–1535.
Current Strategies for Detection and Treatment of Recurrence of Pancreatic Ductal Adenocarcinoma After Resection A Nationwide Survey To the Editor: ancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancerrelated mortality in Europe.1 Even after radical resection, around 75% of patients will experience disease recurrence.2 Detection and treatment of disease recurrence therefore offer a potential strategy to improve overall survival.3 Current Dutch guidelines for pancreatic cancer do not contain recommendations for follow-up frequency or strategy.4 Furthermore, they do not contain recommendations for the treatment of recurrent
P
RESULTS Thirty-nine surgeons from all 19 hospitals in the Netherlands that perform surgery for PDAC responded, resulting in a 81% response rate for active pancreatic surgeons. Four surgeons (10%) declared that they did not directly participate (anymore) in the follow-up of resected patients and only completed the second part of the survey. In Figure 1, results of survey questions that related to the methodology and philosophy of the current practice of follow-up are shown. Approximately 35% of surgeons advocated a less intensive follow-up strategy in case of low performance status due to advanced age or comorbidities. Table 1 shows the percentage of surgeons who adhered to a certain follow-up test at a specific moment. The most used follow-up strategy consisted of appointments at 3, 6, 12, 18, 24, 36, 48, and 60 months, with discharge from further follow-up after this period. After this period, appointments could be conducted by telephone. Different primary goals for followup were identified. Most surgeons (60%) regarded the primary goal to be supportive follow-up. More specifically, this included identifying and treating postoperative complications, monitoring pancreatic endocrine/exocrine insufficiency and nutritional status, patient guidance and reassurance, and guiding in end of life decision making. Seven other surgeons (20%) viewed the primary goal of follow-up to be based more on further therapeutical care, such as early detection and treatment of recurrence and planning of palliative treatment options. The remaining 20% named a combination of supportive and therapeutical goals. Nearly all surgeons (n = 37; 95%) were willing to participate in a new national
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
www.pancreasjournal.com
e73
