Palliative Pancreaticoduodenectomy in Pancreatic and Periampullary Adenocarcinomas
ABSTRACT The objective of the study was to clarify the role of a palliative pancreaticoduodenectomy in both pancreatic and periampullary adenocarcinomas.
Survival outcomes were compared between resections and bypass operations, and between curative (R0) and palliative resections, with a microscopically (R1) and a grossly (R2) positive resection margin.
There were 595 surgical patients, including 207 undergoing bypass operations and 388 undergoing pancreaticoduodenectomies, with 47.4% curative resections (R0) and 17.8% palliative resections (R1 + R2). The overall positive margin rate after a pancreaticoduodenectomy was 27.3% (R1 = 8.0%, R2 = 19.3%). For periampullary adenocarcinomas, there was a significant survival difference between the R0, palliative, and no resection groups. However, there was no significant survival difference between the R0 and palliative resection for pancreatic head adenocarcinoma. Note that the survival outcome after either a curative or a palliative pancreaticoduodenectomy was still better than the survival outcome of a bypass operation.
There was a survival benefit after a pancreaticoduodenectomy regardless of the resection margin or primary origin of the periampullary adenocarcinoma, as compared with a bypass operation. The resection margin after a pancreaticoduodenectomy did not play a role in the survival outcome in pancreatic head adenocarcinoma. Therefore, we recommend that pancreaticoduodenectomies should be attempted whenever possible.
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ABSTRACT: Most survival studies comparing non-radical resections to bypass surgery in patients with pancreatic cancer often do not differentiate between an R1 and R2 resection. The aim of this study was to evaluate whether non-radical R1 and R2 resections have better postoperative outcomes and survival compared to a palliative bypass. A single center cohort study was performed analyzing mortality, morbidity and 1-year survival after R1 (tumor cells within 1 mm from the circumferential margin), R2 and bypass surgery in patients with pancreatic cancer. For the systematic review, studies were identified comparing R1 or R2 resections with bypass, in patients with pancreatic cancer. Postoperative outcomes were compared including the cohort study. The cohort study (n=405) showed higher morbidity rates after R1 (n=191) and R2 (n=11) resections compared to bypass (52% and 73% vs. 34%, p < 0.01). In-hospital mortality did not differ (overall 1.7%). 1-year survival rates were 71%, 46% and 32% after R1, R2 resection and bypass (p=0.6 between R2 and bypass). The systematic review identified 8 studies, after including the cohort study 1535 patients were analyzed. Increased morbidity after R1-R2 resection (48%) compared to bypass (30-34%) was found. Median survival was 14-18 months after R1 resection vs. 9-13 months after bypass and 8.5-11.5 months after R2 resection vs. 7.5-10.7 months after bypass. An R2 resection should be avoided in patients with pancreatic cancer due to its poor prognosis. Survival benefit after an R1 resection, as compared to bypass surgery, justifies a resection despite the increased morbidity rate. Copyright © 2014 Elsevier Ltd. All rights reserved.European Journal of Surgical Oncology 12/2014; 41(2). DOI:10.1016/j.ejso.2014.11.041 · 2.89 Impact Factor
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ABSTRACT: Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first" (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5-8.1 h). The median intraoperative blood loss was 450 mL (ranging 200-900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.Journal of Huazhong University of Science and Technology 10/2013; 33(5):687-91. DOI:10.1007/s11596-013-1181-0 · 0.78 Impact Factor
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ABSTRACT: AIM: To inquire into a question of an overestimation of arterial involvement in patients with pancreatic cancer (PC). METHODS: Radiology data were compared with the findings from 51 standard, 58 extended and 17 total pancreaticoduodenectomies; 9 distal resections with celiac artery (CA) excision; and 28 palliations for PC. The survival of 11 patients with controversial computed tomography (CT) and endoscopic ultrasound data with regard to arterial invasion, after R0/R1 procedures (false-positive CT results, Group A), was compared to survival after eight R2 resections (false-negative CT results, Group B) and after 12 bypass procedures for locally advanced cancer (true-positive CT results, Group C). RESULTS: In all of the cases in group A, operative exploration revealed no arterial invasion, which was predicted by CT. The one-year survival in Group A was 88.9%, and the two-year survival was 26.7%, with a median follow-up of 22 mo. One-year survival was not attained in groups B and C, with a significant difference in survival (P a-b = 0.0029, P b-c = 0.003). CONCLUSION: Arterial encasement on CT does not necessarily indicate arterial invasion. Whenever PC is considered unresectable, endoUS should be used. In patients with controversial CT an EUS data for peripancreatic arteries involvement radical resection might be possible, providing survival benefits as compared to R2- resections or palliative surgery.04/2013; 5(4):83-96. DOI:10.4240/wjgs.v5.i4.83