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8 Quality ofLife after Upper GI Surgery
117
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Patient-Reported Quality ofLife
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After Pancreatic andLiver Surgery
NicoleE.James, ElianaKalakouti,
SwathikanChidambaram, TamaraM.H.Gall,
andMikaelH.Sodergren
9
Introduction
Pancreatic cancer is currently the seventh leading cause of global cancer death and the sixth
most common in the United Kingdom [1]. It is an
aggressive disease, with an overall 5-year survival
rate of less than 7% [1, 2]. Well-established operative techniques include the standard pancreaticoduodenectomy (PD, or Whipple’s procedure)
and pylorus-preserving pancreatoduodenectomy
(PPPD), a modication of the former procedure
[3]. Distal pancreatectomy is the standard procedure for cancer of the body or tail of pancreas
[4]. Primary liver cancer comprises two main histological types: hepatocellular carcinoma (HCC
75–85%); and intra- hepatic cholangiocarcinoma
(ICC 10–15%). It is the third leading cause of
cancer mortality worldwide [5]. Colorectal Liver
N. E. James
Imperial College London, London, UK
e-mail: nicole.james15@imperial.ac.uk
E. Kalakouti · S. Chidambaram
Department of Surgery & Cancer, Imperial College
London, Hammersmith Hospital, London, UK
e-mail: eliana.kalakouti1@nhs.net; swathikan.
chidambaram12@imperial.ac.uk
T. M. H. Gall · M. H. Sodergren (*)
Imperial College London, London, UK
Department of Surgery & Cancer, Imperial College
London, Hammersmith Hospital, London, UK
e-mail: t.gall12@imperial.ac.uk;
m.sodergren@imperial.ac.uk
Metastases (CRLM) is considered secondary
liver cancer and presents in around 40–50% of
colorectal cancer patients. Liver resection with
curative intent is performed for both primary
and secondary liver tumours. There has been a
move towards non-anatomical, parenchymal-preserving minor liver resections over the last two
decades however, major hepatectomy involving
resection of more than three liver segments, and
two-stage hepatectomy is still required for more
extensive disease. Besides surgery, various other
approaches have been developed for managing
liver cancer including radiofrequency ablation
(RFA), trans-arterial chemoembolization (TACE/
TAE) and hepatic arterial infusion chemotherapy (HAIC). More recently, minimally invasive
techniques (laparoscopic and robotic) have been
described for both pancreatic and liver resection
and may offer a faster return to functional activity
and an improved patient experience.
Despite therapeutic intent, both pancreatic and
liver disease have high rates of recurrence.
Further, there is a signicant risk of peri- operative
morbidity after resection. Therefore, there is
increasing emphasis placed on health-related
quality of life (HRQOL) as an outcome measure
as selecting the optimal option is essential in
ensuring high quality care. Patient-reported
HRQOL is the subjective assessment of multiple
components that can be inuenced by the disease
process itself or its treatment, such as physical,
social and emotional wellbeing [5]. As the inci-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
T. Athanasiou et al. (eds.), Patient Reported Outcomes and Quality of Life in Surgery,
https://doi.org/10.1007/978-3-031-27597-5_9
121
122
N. E. James et al.
dence of cancer is predicted to grow in the next
few decades, the need to consider HRQOL after
surgery becomes increasingly important in the
decision-making process. Hence, this systematic
review aims to assess short- and long-term
patient-reported QOL after surgical resection in
pancreatic and liver cancer.
Methods
Literature search methods, inclusion and exclusion criteria, outcome measures and statistical
analysis were dened according to the Preferred
Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA). Patients were not
involved in the conception, design, analysis,
drafting, interpretation or revision of this
research. Hence, ethical approval was not
required and thus not sought for this study.
Literature Search
Inclusion/Exclusion Criteria
Studies in English reporting HRQOL in adult
patients undergoing any resection for liver and
pancreatic cancers, performed in the open or
minimally invasive approach (laparoscopic or
robotic) for any liver or pancreatic lesions were
included.
Data Extraction
Relevant data was entered into Review Manager
5.4 (Cochrane Collaboration, Oxford, United
Kingdom). The following data items were
extracted: year of publication, country of origin,
study design, sample size, key patient characteristics, diagnosis, surgical techniques and intent,
concomitant neoadjuvant/adjuvant/adjunct therapy, QOL instruments used, follow-up rates, time
points of QOL measures. All available numerical
data of QOL measures were also extracted from
the studies.
The following databases were searched:
MEDLINE (1946 until the rst week of March
2021) via OvidSP; MEDLINE in-process and
other non-indexed citations (latest issue) via
OvidSP; Ovid EMBASE (1974 to latest issue); d)
Scopus (1996 till present). The last search was
performed in March 2021. Search terms used
several strings which were linked by standard
modiers in the following order: “liver cancer”,
“hepatocellular carcinoma”, “HCC”, “pancreatic
cancer”, “PDAC”, “pancreatic ductal adenocarcinoma”, “liver resection, “Whipple’s”, “distal
pancreatectomy”, “pylorus-preserving pancreatoduodenectomy”, OR “pancreatoduodenectomy”. A second search was carried out using the
terms “quality of life”, “QALY”, “QOL”, health
related quality of life”, OR “HRQOL”. Both
searches were combined with using the AND
modier. Additionally, the references of included
articles were hand-searched to identify any additional studies.
Data Analysis
Descriptive analysis was performed on the
included studies due to heterogeneity of questionnaires used, and differences in time points
assessing QOL post-surgery and reported outcomes. To improve clarity of results, QOL data
reported in individual studies are grouped in the
following domains, and analysed accordingly:
functional scales (physical, emotional, social),
symptom scales (pain, fatigue, diarrhoea), and
global/overall QOL.
Numerical QOL data extracted from the studies were analysed and reported based on the four
steps validated by The National Cancer Institute
of Canada Clinical Trials Group [6]. These
include: (1) calculating the questionnaire completion rates, (2) calculating the baseline scores,
(3) comparing the changes in scores between and
within treatment groups post-intervention, and
9 Patient-Reported Quality ofLife After Pancreatic andLiver Surgery
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123
Identification
ScreeningIncluded Eligibility
Records identified through
database searching
(n = 4569)
Records after duplicates removed
Full-text articles assessed
(n = 3246)
Records screened
(n = 3246)
for eligibility
(n = 633)
Studies included in
qualitative synthesis
(n = 43)
Additional records identified
through other sources
(n = 0)
Records excluded
(n = 2613)
Full-text articles excluded
(n = 590)
Fig. 9.1 PRISMA chart of the study selection process
nally, (4) determining the proportions of patients
Results
who reported clinically meaningful changes in
scores since baseline [6]. A change of 10% or
more in QOL scores is considered clinically sig-
Study Characteristics ofStudies
inPancreatic Cancer
nicant [6]. Where no baseline scores were
reported in the primary studies, clinically relevant changes were noted. Fig. 9.1 shows the
PRISMA owchart of the study selection
process.
Nineteen studies comprising a total of 1855
patients who had undergone surgical resection
for pancreatic cancer were included in this study
[7–25]. Details of studies as well as demograph-
124
N. E. James et al.
ics of included patients and details on diagnoses
are shown in Table 9.1. Nine studies reported
QOL data after pancreatic resection alone [7,
11–13, 17, 20, 23–25], with either curative or pal-
liative intent. Six studies reported QOL in
patients undergoing surgical resection in combination with adjuvant chemo/radiotherapy [9, 10,
14, 16, 18, 21], 5 with neoadjuvant therapy [8,
10, 14, 15, 22], 2 with vascular resection [17, 22],
2 with ELND [11, 16], and 1 with octreotide as
adjunct therapy [19].
Quality ofLife Assessment
inPancreatic Cancer
A total of 15 different previously validated questionnaires were used (Table9.2). The most commonly used questionnaire was the European
Organisation of Research and Treatment of
Cancer, Quality of Life Questionnaire-C30
(EORTC QLQ-30), a cancer-specic questionnaire incorporating functional scales (physical,
role, cognitive, emotional and social), symptom
scales (fatigue, pain, and nausea and vomiting),
as well as a global health scale [26]. This was
utilised by 11 of the included studies [7, 10–12,
14, 16, 17, 19, 21–23]. Eight studies used a ques-
tionnaire specic for pancreatic diseases – the
EORTC QLQ-PAN26 [7, 11, 14, 19, 21, 23], or
the Functional Assessment of Cancer Therapy-Pa
(FACT-Pa) [14, 19]. Other questionnaires used
included the Gastrointestinal Quality of Life
Index (GIQLI), 36-item Short-Form Survey (SF-
36), Uniscale Global QOL, Medical Outcomes
Study 24 acute-phase questionnaire (MOS24),
Rotterdam Symptom Checklist (RSCL), Sickness
Impact Prole (SIP), and Modied Kurihara’s
questionnaire. Ten studies used a single questionnaire, 3 studies used 2 different questionnaires,
and 6 studies used 3 or more different
questionnaires.
Study Characteristics ofStudies
inLiver Cancer
The 24 studies included comprised a total of
3654 participants (range 36–410) (Table 9.3).
Fifteen studies were prospective; ve were retrospective cohorts; one was a cross-sectional study;
one was a secondary analysis of two prospective
studies; one was a predened sub-study of a randomised controlled trial; and one was a randomised controlled trial. All studies included
patients who underwent intervention from 1988
to 2019. Four (17%) were multicentre studies.
Indication for liver resection (LR) in all studies
included HCC only (twelve studies), Liver
Cancer (eight studies), benign only (two studies),
benign and malignant liver tumours (one study)
and colorectal liver metastases (CRLM) only
(one study). Six studies reported outcomes for
HRQOL in LR as compared to alternative treatment modalities (TACE, RFA, NT, HAIC). Four
studies reported outcomes for HRQOL in LR in
relation to peri-operative interventions. Three
studies reported on HRQOL in Lap Vs Open LR
using the SF-36. Ten studies analysed predictors
of HRQOL in LR. Two studies reported on
HRQOL in LR in benign disease only.
Quality ofLife Assessment inLiver
Cancer
A total of 20 instruments were used and included
the following: FACT-G, FACT-Hep, FACT-An,
FACT-F, FACT-H, EORTC QLQ-C30, QLQHCC18, SF-36, SF-12, HADS, SAS, SDS, VAS,
QNS, GQLI, Global Rating Scale, BAI, BDI,
Centre for Epidemiologic Studies-Depression
and QLQ-LMC21 (Table9.4). 9 studies used the
FACT-Hep instrument, 8 studies the EORTC
QLQ –C30, 7 studies [the SF-36, and 3 studies
other instruments. A total of 22 studies used one
9 Patient-Reported Quality ofLife After Pancreatic andLiver Surgery
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Neoadjuvant/adjuvant/
adjunct therapy (%)
Adjuvant chemotherapy
(51.5)
First line
intervention (%)
Whipple’s (10.3),
PPPD (67.6), TP
(8.82), DP (8.82),
others (4.41)
PD (100)
PD (46.6),
palliative (53.4)
Palliative PD: Adjuvant
chemotherapy (71.4);
DLB: Adjuvant
chemotherapy (76)
Palliative PD
(21.4): PPPD (43),
Whipple’s (57);
DLB (78.6)
(continued)
Neoadjuvant
chemotherapy with
gemcitabine and cisplatin
PD (89): R0
resection (80),
portal vein
resection (12)
125
Mean age 66years (29–82),
57.4% male, mean tumour
size 3.2cm (0.6–8.0);
resection margin status: 41.2%
R0, 48.5% R1, 10.3% NA
ampullary carcinoma (17.6),
cholangiocarcinoma (2.94),
neuroendocrine tumour
(5.88), IPMN (10.3), other
Sample
size Diagnosis (%) Patient characteristics
68 Adenocarcinoma (60.3),
University
Medical
Centre
Utrecht, The
Netherlands
Single-centre
prospective
cohort
Mean age 65.9years (10.2),
50% male, mean duration of
disease 3.2months (2.7),
tumour size 8cm (3.8)
(pre) malignancy (2.94)
(85.0), duodenal cancer
(15.0), cancer of lower part
of gallbladder (5.0), chronic
pancreatitis (5.0); positive
lymph nodes (90.0%),
metastatic disease (57.9)
20 Cancer of head of pancreas
Attikon
University
General
Hospital,
Greece
Single-centre
prospective
cohort
PD: Mean age 62years
(32–82), 54% male, 90% and
10% ASA grade 1–2 and 3–4
respectively; No PD: Mean
age 68years (47–93), 51%
male
Palliative PD: Mean age
63.5years (47–81), 47.6%
adenocarcinoma (49),
ampullary adenocarcinoma
(29), duodenal
adenocarcinoma (2),
carcinoma in situ (2), other
benign tumours (18)
tumours with either micro/
88 PD: Pancreatic
University
Hospitals
Bristol NHS
Foundation
Single-centre
prospective
cohort
Trust, UK
196 PD group: Locally advanced
University
Hospital of
Single-centre
prospective
male, DLB: Mean age
65years (35–87), 52.6% male
Median age 59years, 57%
male
macroscopic residual tumour
mass in mesenteric root or
retroperitoneum (100)
Resectable adenocarcinoma
of pancreatic head (92.9),
metastatic disease (7.1)
28
Kiel, Germany
cohort
University
Hospital of
Zurich,
Switzerland
Single-centre
prospective
phase II trial
Heerkens
Author, year
Table 9.1 Study and patient characteristics
etal., 2016
of publication Study design Location
Arvaniti
etal., 2016
Rees etal.,
2013
Walter
etal., 2011
Heinrich
etal., 2008
126
Neoadjuvant/adjuvant/
adjunct therapy (%)
PD with VR
First line
intervention (%)
(28.5), PD with
AR (8.9),
Palliative therapy:
VP (41.6), AP
(21.0)
PPD (37.4), PPPD
(62.6), ELA (76.9)
Neoadjuvant/adjuvant
chemo/radiotherapy
(unspecied)
PPPD (88.3),
Whipple’s (11.7)
N. E. James et al.
VR: Median age 52years
214 VR: Adenocarcinoma (91.8),
Sample
size Diagnosis (%) Patient characteristics
Pancreatic
Single-centre
(continued)
(28–72), 62.3% male; AR:
Median age 46years (36–70),
78.9% male; VP: Median age
53years (31–84), 56.2% male;
AP: Median age 58years
(30–76), 71.1% male
acinic cell carcinoma (4.9),
other carcinoma (3.3), actual
blood vessel invasion (68.9);
AR: Adenocarcinoma (94.7),
acinic cell carcinoma (5.2),
actual blood vessel invasion
(78.9); VP: Adenocarcinoma
(90.0), acinic cell carcinoma
(3.8), other carcinoma (6.4);
Centre, Union
Hospital,
Wuhan, China
retrospective
analysis of
prospectively
gathered data
PPD: Mean age 63.1years
(39–76), 52.9% male, 82%
R0; PPPD: Mean age
65.4years (48–83), 45.6%
male, 89% R0; ELA: Mean
AP: Adenocarcinoma (92.3),
acinic cell carcinoma (5.1),
other carcinoma (2.6)
pancreatic head (100)
Germany 91 Ductal adenocarcinoma of
Single-centre
prospective
cohort
age 63.5years (39–83), 50%
male, 87% R0
Mean age 62.0years (11.7),
57.4% male, mean BMI 24.2
(3.7), 36.0% had pre-surgery
endoscopic biliary stenting
[ductal carcinoma (66.9),
IPMN (24.1), nonfunctioning
endocrine tumour (4.8),
serous cystadenoma (2.8)];
neoplasm of papilla of Vater
(16.8), chronic pancreatitis
(4.1), other periampullary
197 Pancreatic neoplasia (73.6)
Sant’Orsola-
Malpighi
Hospital,
G.B.Rossi
Hospital, San
Raffaele
Hospital; Italy
Multi-centre
prospective
cohort
neoplasia (5.6). Malignant
disease (83.2), benign
disease (16.8)
Author, year
Table 9.1
Wang etal.,
2008
of publication Study design Location
Schniewind
etal., 2006
Pezzilli
etal., 2011
9 Patient-Reported Quality ofLife After Pancreatic andLiver Surgery
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Resectable disease:
2cycles of neoadjuvant
chemoradiation (100),
2cycles adjuvant
PD (48.1): R0
radical resection
(53.8), R1
palliative resection
(46.2); DBP
(31.5), laparotomy
(20.4)
Surgical resection
(65.4);
unresectable
chemotherapy (72)
disease (34.6):
4cycles of
chemoradiation
Retrocolic group:
Octreotide prophylaxis
(52.6); antecolic group:
Octreotide (48.9)
with gemcitabine
and oxaliplatin
Retrocolic
anastomosis (52.1)
with PPPD (89.5);
antecolic
anastomosis (47.9)
with PPPD (82.9)
PD (36.4),
palliative
chemotherapy
No PD:
127
(continued)
(63.6)
R0: Mean age 60.2years
(45–74), 50% male; R1: Mean
age 64.0years (44–80), 50%
male, 16.7%; DBP: Mean age
57.2years (40–70), 41.2%
male; Laparotomy: Mean age
61.0years (48–75), 54.5%
male
Median age 64years (42–82).
52.7% male
(48.1), non-resectable
tumours with jaundice and
gastric outlet obstruction
(31.5)
Poland 54 Resectable pancreatic cancer
Single-centre
prospective
cohort
resectable pancreatic
Canada 55 Borderline resectable (65),
Multi-centre
prospective
Retrocolic group: Mean age
adenocarcinoma (35)
65 Retrocolic group:
The
phase II trial
Multi-centre
62.6years (11.0), 44.7% male,
BMI 25.3 (4.2), 94.7%
Karnofsky performance
score≥80, 26.3%, 60.5% and
13.2% ASA grades I, II and III
respectively; Antecolic
group: Mean age 66.0years
(7.9), 68.6% male, BMI 24.9
(3.8), 88.6% Karnofsky
performance score≥80,
Adenocarcinoma (86.8),
other (pre)malignant lesions
(10.5), chronic pancreatitis or
other benign lesion (2.6);
Antecolic group:
Adenocarcinoma (80), other
(pre)malignant lesions (11.4),
chronic pancreatitis or other
benign lesion (8.6)
Netherlands
randomised
controlled trial
11.4%, 68.6% and 20% ASA
grades I, II and III respectively
PD: Mean age 66.8years
(11.0), 53.1% male, BMI 24.1
(3.1), 16.1% diabetic;
(87.5), T4 (3.1), N1 (68.8);
No PD: T1–2 disease (16),
Norway 88 PD: T2 disease (9.4), T3
Single-centre
prospective
observational
Mean age 69.0years (11.6),
45.5% male, BMI 22.7 (4.3),
14.3% diabetic
T3–4 (84)
cohort
Kostro and
Śledziński,
2008
Serrano
etal., 2015
Eshuis
etal., 2015
Nordby
etal., 2013
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