Palliative Pancreaticoduodenectomy in Pancreatic and Periampullary Adenocarcinomas
Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan. Pancreas
(Impact Factor: 2.96).
01/2012; 41(6):882-7. DOI: 10.1097/MPA.0b013e31823c9d46
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.
Available from: Benediktas Kurlinkus
- "Deciding the best option depends on tumour stage, patient preferences, age, clinical situation and the estimated prognosis, but is still a matter of debate. This highlights the importance of survival analysis done so far comparing patients undergoing these different treatment methods -. However, there are still no clear indications when which method should be used. "
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ABSTRACT: Background: Pancreatic ductal adenocarcinoma is the fourth most common reason of death among oncological diseases with ever increasing mortality. At the time of diagnosis, patients are usually suitable for three ways of treatment: radical, palliative surgery or stenting. Deciding the best option depends on clinical situation, but is still a matter of debate.
Methods: We performed a retrospective research of patients with stage II pancreatic head cancer treated in our clinic between years 2002-2014. Four groups were formed according to the used treatment method: group A: radical surgery with R0 (microscopic tumour clearance) margin; group B: radical surgery with R1 (presence of tumour cells within 1 mm of the resection margin) margin; group C: biliary tract stenting; group D: biliodigestive anastomosis. Clinical data and most importantly the survival of these patients were compared.
Results: 200 patients were involved in the final analysis, 82 (41%) of them were IIA and 118 (59%) were IIB. Group A consisted of 113 patients; group B consisted of 28 patients; group C consisted of 33 patients; group D consisted of 26 patients. In patients with IIA stage, group A had the highest survival rate compared with other groups, mean survival was 3.242 versus 1.600; 0.454; 0.652 years. Patients with IIB stage of cancer similarly had longer survival in group A versus other groups, 1.720 versus 0.931; 0.713; 0.957 years.
Conclusions: Patients with IIA and IIB stage of pancreatic cancer benefit the most from radical surgery with R0 margin. However, for patients with lymph node involvement (stage IIB) and when achieving R0 margin is hardly possible, neoadjuvant treatment seems promising, but we need further randomized controlled trials to fully confirm its effectiveness.
Available from: Viacheslav I. Egorov
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To inquire into a question of an overestimation of arterial involvement in patients with pancreatic cancer (PC).
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).
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).
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.
Available from: Meng Xu
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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.
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