Journal of Integrative Oncology

Introduction: Controversy about Pancreatico-Duodenectomy (PD) has persisted since it was first performed by Kausch a century ago and later popularised by Whipple. Evidence that a certain critical caseload volume is required to undertake this kind of surgery with low mortality has been the subject of some debate. Definitions of high and low volume centres and surgeons have been proposed but they differ greatly between health systems and countries.
The objective of this analysis was to determine whether it is possible to deliver pancreatico-duodenectomy at global standards in a regional city and to see if we can help define the minimum acceptable number of procedures annually compatible with providing such a service.
Methods: A ten-year retrospective study from the period of October 2002 to October 2012 was undertaken in the 1 public and 2 private hospital in Newcastle Australia where all the PDs for a regional population of 840000 were performed.
Results: 123 pancreatico-duodenectomies were performed in this period. The mean number of operations performed each year including all hospitals combined was 12.3. This is equivalent to a medium volume centre by European definitions. The number of operations per surgeon per annum ranged from 0.2 per year to 5.8. 83.7% of patients suffered no significant complications; 30-day mortality was 4.1%. Significant differences were found between surgeons total significant complication rates, which ranged from 8.6% to 50%. 30-day mortality ranged from 0% to 50%. 3 surgeons performed >3 operations per year. These were all designated medium volume surgeons and they performed 91% of all PDs in this series (112/123). The 3 other surgeons performed 9% (11/123) and were designated very low volume surgeons. One hospital performed only 4 PDs during the study period and was designated a very low volume hospital (<1case per annum). When the data from medium volume surgeons and
medium volume hospitals was compared with the data from very low volume surgeons and hospitals there was a statistically significant difference in overall complication rates and mortality. Exclusion of the very low volume surgeons and the very low volume institution was associated with 1.9% 30-day mortality, a 12% significant morbidity and a 31% actuarial 5-year survival for periampullary malignancy.
Conclusion: There are both surgeon and hospital volume effects on outcome after PD. We have demonstrated that specialised Upper GI/HPB surgeons can achieve pancreatico-duodenectomy results in a medium volume centre equivalent to those achieved high volume centres.

As the number of adult survivors of childhood cancers continues to grow, the challenges of long-term follow-up (LTFU) care escalate. When adult survivors of childhood cancer are followed in a pediatric oncology setting their care can be fragmented, leading to barriers for both providers and patients. To address the need for continued LTFU care as survivors age out of the pediatric medicine arena, the STAR (Survivors Taking Action & Responsibility) Program was established in June of 2001 within an adult oncology setting at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. The 11-year old program currently has over 320 survivors enrolled (ages 19-60, all diagnosed at 21 years of age or younger). The program’s three main foci are (1) comprehensive, long-term followup clinical care, (2) patient/family education and (3) research. The STAR team includes a general internal medicine physician, a clinical health psychologist, and an advanced practice nurse with expertise in childhood cancer and late effects from cancer therapy. The program facilitates referrals to specialty care as appropriate. Patient-oriented events allow opportunities for networking, outreach and education to assist patients in becoming autonomous in their comprehensive care and survivorship. The purpose of this article is to share our experiences with the implementation of this program, offer information on how to build a similar model in institutions caring for childhood cancer patients and adult survivors of childhood cancer.

Aim: To examine the efficacy of oral rinsing against chemotherapy-induced stomatitis.
Methods: Consecutive fluoropyrimidine-treated patients with stomach and colorectal cancer were enrolled from April 2009 to March 2011 (n=43; Group 1) and from January 2012 to December 2012 (n=45; Group 2). The incidence and severity of stomatitis were compared between Group 1 patients, who were instructed to gargle with lemonflavored water 6 times daily, and Group 2 patients, who did not receive any specific guidance. Among patients in the gargle group, we determined the rate of gargling compliance as well as quality of life (QOL) scores, and evaluated the impact of rebamipide use on patient outcomes.
Results: The incidence of stomatitis was significantly reduced in Group 1 (14.0%) compared to that in Group 2 (33.3%) and its severity in the former group was milder. Among patients using lemon-flavored water, concomitant rebamipide use had no statistically significant impact on stomatitis incidence (with versus without rebamipide, 19.0% versus 9.0%), the rate of gargling compliance (96.4% versus 94.2%), or QOL scores.
Conclusions: Oral rinse with lemon-flavored water is useful for the symptomatic control of fluoropyrimidineinduced stomatitis, regardless of the presence or absence of rebamipide.