Current Literature

Laparoscopy before Open Surgery has Value for Patients with Pancreatic Ductal Adenocarcinoma

Gudmundsdottir H, Yonkus JA, Alva-Ruiz R, et al. Yield of Staging Laparoscopy for Pancreatic Cancer In the Modern Era: Analysis of Over 1000 Consecutive Patients. J Am Coll Surg. 2023, in press.

This article reported data from a single-institution retrospective study that was designed to determine the efficacy and clinical value of exploratory laparoscopy used to define the extent of disease in patients with pancreatic ductal adenocarcinoma (PDAC) prior to open surgery. Positive laparoscopy (PL) was defined as discovery of extrapancreatic metastases and/or identification of malignant cells in peritoneal lavage fluid.

In addition, the study aimed to discover risk factors associated with increased rates of PL. The rate of PL in the study cohort (n = 1004) was 18%; the majority of these patients were found to have extrapancreatic metastatic disease that was not clearly defined on preoperative imaging.

Patients who received neoadjuvant chemotherapy had lower rates of PL. This finding led the investigators to suggest that patients should undergo exploratory laparoscopy prior to finalizing the decision to use neoadjuvant therapy. Data presented in the article showed that earlier exploratory laparoscopy, performed as a separate procedure, helped identify additional patients who were candidates for neoadjuvant therapy.

Risk factors for PL included younger age, tumor location in the body and tail of the pancreas, larger tumor size, indeterminate extrapancreatic lesions on preoperative imaging, and elevated CA 19-9 levels. In patients with no indeterminate extrapancreatic lesions on preoperative imaging, positive PL rates were 1.6% in patients with no risk factors and 42% in patients with multiple risk factors.

The authors concluded that because of the limited sensitivity of preoperative imaging, preoperative laparoscopy has value for patients with PDAC, particularly when risk factors for PL are present.

Preoperative Colonic Prehabilitation has Significant Potential Value as a Means of Reducing Postoperative SSI Risk

Alverdy JC. Rationale for Colonic Pre-Habilitation Prior to Restoration of Gastrointestinal Continuity. Surg Infect (Larchmt) 2023;24(3):265-70. doi: 10.1089/sur.2023.001

In this review article, John C. Alverdy, MD, FACS, provided a clear and valuable definition of the microbiome, a description of the role of the gut microbiome in the pathophysiology of postoperative surgical site infection (SSI) including anastomotic leak, and the value of prehabilitation of the colonic microbiome using preoperative, directed dietary therapy.

Data cited in the article noted that colonization of the microbiome with organisms that cause SSI can result in transfer of these microorganisms to immune cells that then migrate to sites of SSI, resulting in implantation of causative organisms in these sites. Implantation into intestinal anastomotic sites can contribute to anastomotic leakage. Additional data showed that prehabilitation of the microbiome in experimental animals led to reduced rates of anastomotic leakage.

The author noted that preoperative bowel cleansing and the trend toward usage of more powerful and broader spectrum antibiotics during preoperative bowel preparation are contributing to the development of a more dangerous microbiome that may cause increases in rates of anastomotic leakage and SSI. Current data, cited in the article, indicate that SSI, including anastomotic leakage, may occur in up to 20% of patients undergoing colonic surgical procedures.

The article presented evidence for favorable alteration of the microbiome after a short course of dietary therapy that included changing from a Western diet to a low-fat, high fiber diet prior to operation. Dietary prehabilitation proposed in the review article would require 2–3 days, be guided by preoperative assessments of the colonic microbiome, and be supervised by a nutritionist. Based on evidence presented in the review, Dr. Alverdy concluded that preoperative colonic prehabilitation has significant potential value as a means of reducing postoperative SSI risk.